GQE-120117-aba27d74f6

1 Dec 2017
# Item Codes and Description Quantity Price
1 Service 1  –  [For Tooth Number(s): (16,47)]
  • d-011: Comprehensive oral examination
  • d-013: Oral examination – limited
  • d-015: Consultation – extended
2x(81.50)
  • 2x(53.55)
  • 2x(27.95)
  • 2x(0.00)
163.00
Sub Total (A): 163.00
Cover Payout (D): 0.00
Gap Total (Est.): (C – D) 163.00

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