GQE-120117-ac54aebaeb

1 Dec 2017
# 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

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