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OR-13 Treatment Series: Class II Div 1 (2 BiC extraction) L1-4	$381.00	OR-13 Treatment Series: Class II Div 1 (2 BiC extraction) L1-4 quantity	$381.00	×
OR-14 Treatment Series: Class II Div 2 (2 up BiC extraction) E1-4	$381.00	OR-14 Treatment Series: Class II Div 2 (2 up BiC extraction) E1-4 quantity	$381.00	×
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Subtotal	$762.00
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State Tax	$55.24
Total	$817.24