#	Item Codes and Description	Quantity	Price
1	Service 1  –  [For Tooth Number(s): (28,46)] 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
	Sub Total (A):		352.00
	Cover Payout (D):		176.00
	Gap Total (Est.):	(C – D)	176.00