GQE-120117-fa6f20a103

1 Dec 2017
# Item Codes and Description Quantity Price
1 Service 1  –  [For Tooth Number(s): (34,37)]
  • d-011: Comprehensive oral examination
  • d-013: Oral examination – limited
  • d-015: Consultation – extended
2x(81.50)
  • 2x(53.55)
  • 2x(27.95)
  • 2x(0.00)
163.00
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-013  –  [For Tooth Number(s): (38)]
  • d-013: Oral examination – limited
1x(27.95)
  • 1x(27.95)
27.95
4 d-022a  –  [For Tooth Number(s): (17)]
  • d-022a: Step down fee for additional radiographs on same day(limit 5)
1x(30.95)
  • 1x(30.95)
30.95
Sub Total (A): 266.40
Cover Payout (D): 239.76
Gap Total (Est.): (C – D) 26.64

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