1 Surface 425.00 4,155.00 7/28/2016 Comp. W. Etch 1 Surface 425.00 4,580.00 7/28/2016 Ortho treatment adult 7,500.00 12,080.00 7/28/2016 Cement Crown 0.00 12,080.00 8/11/2016 AMERICAN EXPRESS 2,880.00 9,200.00 Account Total 9,200.00 If payment has been sent, please disregard this statement