#	Item Codes and Description	Quantity	Price
1	Service 1  –  [For Tooth Number(s): (42)] d-011: Comprehensive oral examination d-013: Oral examination – limited d-015: Consultation – extended	1x(81.50) 1x(53.55) 1x(27.95) 1x(0.00)	81.50
	Sub Total (A):		81.50
	Cover Payout (D):		0.00
	Gap Total (Est.):	(C – D)	81.50