#	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