GQE-120117-a01a84d22e

1 Dec 2017
# 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

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