GQE-120117-98fab8e0d8

1 Dec 2017
# 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

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