GQE-120117-f6dbe7f452

1 Dec 2017
# Item Codes and Description Quantity Price
1 Service 1  –  [For Tooth Number(s): (31,36)]
  • d-011: Comprehensive oral examination
  • d-013: Oral examination – limited
  • d-015: Consultation – extended
2x(180.00)
  • 2x(57.00)
  • 2x(39.00)
  • 2x(84.00)
360.00
Sub Total (A): 360.00
Cover Payout (D): 280.00
Gap Total (Est.): (C – D) 80.00

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