Aesthetic Smiles Studio STATEMENT

Frida Kahlo 10410 , 202 10/16/2023

Tijuana, BC 22010 Account Number 36
(619)356-4531 Amount Due Date Due Amount Enclosed
0.00 Upon Receipt

CREDIT CARD TYPE

Yesenia Machuca 3 DIGIT CSV

1728 Rich ST. APT. 9 EXPIRES
Sacramento, CA 95825
AMOUNT APPROVED

NAME

SIGNATURE
PLEASE DETACH AND RETURN THE UPPER PORTION WITH YOUR PAYMENT

Total: $0.00
-Ins Estimate: $0.00
=Balance: $0.00
0-30 31-60 61-90 over 90
0.00 0.00 0.00 0.00

Yesenia Machuca
Date Patient Code Tooth Description Charges Credits Balance
07/25/2022 Yesenia D0150 comprehensive oral evaluation – new or established 30.00 30.00
patient
07/25/2022 Yesenia D3346 13 retreatment of previous root canal therapy – anterior 300.00 330.00
07/25/2022 Yesenia Pay Credit Card $30.00 30.00 300.00
07/26/2022 Yesenia D3347 12 retreatment of previous root canal therapy – bicuspid 300.00 600.00

07/26/2022 Yesenia D3346 14 retreatment of previous root canal therapy – anterior 300.00 900.00
07/27/2022 Yesenia D2799 12 Provisional Crown 80.00 980.00
07/27/2022 Yesenia D2799 13 Provisional Crown 80.00 1,060.00
07/27/2022 Yesenia D2799 14 Provisional Crown 80.00 1,140.00
07/27/2022 Yesenia Pay Credit Card $1,140.00 1,140.00 0.00
08/08/2022 Yesenia D2954 12 Prefabricated Post and Core, in Addition to Crown 100.00 100.00
08/08/2022 Yesenia D2954 13 Prefabricated Post and Core, in Addition to Crown 100.00 200.00
08/08/2022 Yesenia D2750 14 Zirconia Crown 400.00 600.00
08/08/2022 Yesenia D2954 14 Prefabricated Post and Core, in Addition to Crown 100.00 700.00
08/08/2022 Yesenia Pay Credit Card $900.00 - Prepayment 900.00 -200.00
08/08/2022 Yesenia Stmt Statement-InPerson
08/09/2022 Yesenia D2330 11 M resin-based composite – one surface 100.00 -100.00
08/12/2022 Yesenia D2750 12 Zirconia Crown 400.00 300.00
08/12/2022 Yesenia D2750 13 Zirconia Crown 400.00 700.00
08/12/2022 Yesenia Pay Credit Card $700.00 700.00 0.00
08/24/2022 Yesenia Stmt Statement-InPerson
08/24/2022 Yesenia Stmt Statement-InPerson
08/24/2022 Yesenia Stmt Statement-Email
08/24/2022 Yesenia Stmt Statement-Email
07/03/2023 Yesenia D2750 2 Zirconia Crown 400.00 400.00
07/03/2023 Yesenia D2799 2 Provisional Crown 50.00 450.00
07/03/2023 Yesenia D2950 2 Core Build Up 100.00 550.00
07/03/2023 Yesenia D3330 2 endodontic therapy, molar (excluding final 300.00 850.00
restoration)
07/03/2023 Yesenia D2799 3 Provisional Crown 50.00 900.00
07/03/2023 Yesenia D6240 3 Bridge Pontic, Zirconia 380.00 1,280.00
 Date Patient Code Tooth Description Charges Credits Balance
07/03/2023 Yesenia D2799 4 Provisional Crown 50.00 1,330.00
07/03/2023 Yesenia D6240 4 Bridge Pontic, Zirconia 380.00 1,710.00
07/03/2023 Yesenia D2750 5 Zirconia Crown 400.00 2,110.00
07/03/2023 Yesenia D2799 5 Provisional Crown 50.00 2,160.00
07/03/2023 Yesenia D2950 5 Core Build Up 100.00 2,260.00
07/03/2023 Yesenia D3320 5 endodontic therapy, bicuspid tooth (excluding final 250.00 2,510.00
restoration)
07/03/2023 Yesenia Pay Credit Card $2,510.00 2,510.00 0.00
10/13/2023 Yesenia D1120 Prophy, Adult 60.00 60.00
10/13/2023 Yesenia D2330 8 D resin-based composite – one surface 60.00 120.00
10/13/2023 Yesenia Pay Credit Card $120.00 120.00 0.00

Ermilo Machuca
Date Patient Code Tooth Description Charges Credits Balance
08/08/2022 Ermilo D0150 comprehensive oral evaluation – new or established 30.00 30.00
patient
08/08/2022 Ermilo D2954 30 Prefabricated Post and Core, in Addition to Crown 100.00 130.00
08/08/2022 Ermilo D3320 30 endodontic therapy, bicuspid tooth (excluding final 250.00 380.00
restoration)
08/08/2022 Ermilo Pay Credit Card $780.00 - Prepayment 780.00 -400.00
08/15/2022 Ermilo D2750 30 Zirconia Crown 400.00 0.00
10/13/2023 Ermilo D1120 Prophy, Adult 60.00 60.00
10/13/2023 Ermilo Pay Credit Card $60.00 60.00 0.00