#	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