GQE-120117-c1c5ab9b7b

1 Dec 2017
# Item Codes and Description Quantity Price
1 Service 1  –  [For Tooth Number(s): (15,24,47)]
  • d-011: Comprehensive oral examination
  • d-013: Oral examination – limited
  • d-015: Consultation – extended
3x(81.50)
  • 3x(53.55)
  • 3x(27.95)
  • 3x(0.00)
244.50
2 Procedure 1
  • d-012: Periodic oral examination
  • d-014: Consultation
  • d-015: Consultation – extended
1x(44.50)
  • 1x(44.50)
  • 1x(0.00)
  • 1x(0.00)
44.50
3 d-031
  • d-031: Extraoral radiograph – maxillary, mandibulare – per exposure
1x(0.00)
  • 1x(0.00)
0.00
Sub Total (A): 289.00
Cover Payout (D): 273.40
Gap Total (Est.): (C – D) 15.60

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