#	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