Whilst, depending on your heading structure, it would be possible to produce most of what you're after, a Table of Contents (TOC) field cannot generate a page range. Consequently, your last column would not be possible with a TOC field. If you need that, you'll have to abandon the TOC field altogether and use a table, for example, with cross-references. Even then, producing the last column is likely to be a challenge.

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Cheers,
Paul Edstein
[Fmr MS MVP - Word]