#	Item Codes and Description	Quantity	Price
1	Abscess Drainage d-013: Oral examination – limited d-022: Intraoral periapical or bitweing radiograph – per exposure d-037: Panoramic radiograph – per exposure d-392: Drainage of abscess	1x(259.90) 1x(27.95) 1x(37.65) 1x(95.80) 1x(98.50)	259.90
2	d-011 d-011: Comprehensive oral examination	1x(53.55) 1x(53.55)	53.55
	Sub Total (A):		313.45
	Cover Payout (D):		288.07
	Gap Total (Est.):	(C – D)	25.38