#	Item Codes and Description	Quantity	Price
1	Service 1  –  [For Tooth Number(s): (16,18)] d-011: Comprehensive oral examination d-013: Oral examination – limited d-015: Consultation – extended	2x(176.00) 2x(55.00) 2x(45.00) 2x(76.00)	352.00
2	Procedure 1 d-012: Periodic oral examination d-014: Consultation d-015: Consultation – extended	1x(182.00) 1x(50.00) 1x(56.00) 1x(76.00)	182.00
3	d-011 d-011: Comprehensive oral examination	1x(55.00) 1x(55.00)	55.00
	Sub Total (A):		589.00
	Cover Payout (D):		353.40
	Gap Total (Est.):	(C – D)	235.60