Crestview Family Dentistry STATEMENT

101 East Fourth Ave. 05/12/2025

Ste. D Account Number 20389
Crestview, FL 32539-2401 Amount Due Date Due Amount Enclosed
(850)683-3544 0.00 Upon Receipt

CREDIT CARD TYPE

3 DIGIT CSV
Michelle McLemore
4174 Second Ave EXPIRES
Laurel Hill, FL 32567
AMOUNT APPROVED

NAME

SIGNATURE

PLEASE DETACH AND RETURN THE UPPER PORTION WITH YOUR PAYMENT

Total: $0.00
-Ins Estimate: $0.00
=Balance: $0.00

Scan QR Code to make a payment

For your convenience, we have attached a QR code for you to pay off your balance.

Please don't hesitate to contact us at 850.683.3544 if you have any questions or need assistance regarding your account. We value
your business and would like to work together to resolve this matter amicably.

Thank you for your prompt attention to this matter.

Sincerely,

Crestview Family Dentistry

0-30 31-60 61-90 over 90
0.00 0.00 0.00 0.00

If your bill is over 90 days past due, call our office immediately or simply scan the QR
Code above to pay off your balance.

If we do not receive payment, we have no other recourse but to send you to Collections.

Michelle McLemore
Date Patient Code Tooth Description Charges Credits Balance
07/24/2023 Michelle D0140 limited oral evaluation - problem focused 101.00 101.00
07/24/2023 Michelle D0220 intraoral - periapical first radiographic image 39.00 140.00
07/24/2023 Michelle D0330 panoramic radiographic image 141.00 281.00
07/24/2023 Michelle D0364 cone beam CT capture and interpretation with limited 263.00 544.00
field of view – less than one whole jaw
07/24/2023 Michelle Adjust Discount 263.00 281.00
07/24/2023 Michelle Pay Credit Card $0.01 - Prepayment 0.01 280.99
07/24/2023 Michelle Txfr 0.00 280.99
07/24/2023 Michelle Pay Credit Card $84.99 84.99 196.00
 Date Patient Code Tooth Description Charges Credits Balance
07/24/2023 Michelle Claim Pri Claim $281.00 Sun Life Financial
Received 08/10/2023
Payment: $85.60
07/24/2023 Michelle Stmt Statement-InPerson
08/07/2023 Michelle D9239 intravenous moderate (conscious) 368.00 564.00
sedation/analgesia- first 15 minutes
08/07/2023 Michelle D2950 19 core buildup, including any pins when required 332.00 896.00
08/07/2023 Michelle D3330 19 endodontic therapy, molar tooth (excluding final 1,208.00 2,104.00
restoration)
08/07/2023 Michelle Pay Credit Card $1,212.32 - Prepayment 1,212.32 891.68
08/07/2023 Michelle Txfr 0.00 891.68
08/07/2023 Michelle Claim Pri Claim $1,908.00 Sun Life Financial
Received 09/26/2023
Payment: $604.99
08/07/2023 Michelle Stmt Statement-InPerson
08/08/2023 Michelle D9239 intravenous moderate (conscious) 368.00 1,259.68
sedation/analgesia- first 15 minutes
08/08/2023 Michelle D6104 19 bone graft at time of implant placement 688.00 1,947.68
08/08/2023 Michelle D7210 19 extraction, erupted tooth requiring removal of bone 350.00 2,297.68
and/or sectioning of tooth, and including elevation of
mucoperiosteal flap if indicated
08/08/2023 Michelle Adjust Discount 350.00 1,947.68
08/08/2023 Michelle Adjust Discount 368.00 1,579.68
08/08/2023 Michelle Pay Credit Card $1,406.80 - Prepayment 1,406.80 172.88
08/08/2023 Michelle Claim Pri Claim $1,406.00 Sun Life Financial
Received 05/14/2024
NO PAYMENT
08/08/2023 Michelle Stmt Statement-InPerson
08/10/2023 Michelle InsPay Insurance Payment for Claim 07/24/2023 85.60 87.28
08/22/2023 Michelle POT Post Operative 0.00 87.28
09/26/2023 Michelle InsPay Insurance Payment for Claim 08/07/2023 604.99 -517.71
10/24/2023 Michelle POT Post Operative 0.00 -517.71
11/02/2023 Michelle D9239 intravenous moderate (conscious) 368.00 -149.71
sedation/analgesia- first 15 minutes
11/02/2023 Michelle D6010 19 surgical placement of implant body: endosteal 1,890.00 1,740.29
implant
11/02/2023 Michelle Pay Credit Card $984.29 - Prepayment 984.29 756.00
11/02/2023 Michelle Txfr 0.00 756.00
11/02/2023 Michelle Claim Pri Claim $2,258.00 Sun Life Financial
Received 04/25/2024
NO PAYMENT
11/02/2023 Michelle Claim Pri Claim $2,258.00 METLIFE*
Received 05/13/2024
Payment: $310.20
11/02/2023 Michelle Stmt Statement-InPerson
11/16/2023 Michelle N4101 Post Op 0.00 756.00
02/05/2024 Michelle N4101 Post Op 0.00 756.00
02/20/2024 Michelle D6057 19 custom fabricated abutment – includes placement 578.00 1,334.00
02/20/2024 Michelle D6058 19 abutment supported porcelain/ceramic crown 1,433.00 2,767.00
02/20/2024 Michelle Txfr 0.00 2,767.00
02/20/2024 Michelle Pay Credit Card $1,206.60 - Prepayment 1,206.60 1,560.40
02/20/2024 Michelle Claim Pri Claim $2,011.00 Sun Life Financial
Received 04/25/2024
NO PAYMENT
02/20/2024 Michelle Claim Pri Claim $2,011.00 METLIFE*
Received 01/24/2025
NO PAYMENT
02/20/2024 Michelle Stmt Statement-InPerson
03/26/2024 Michelle N4119 19 All Cer Crn Seat 0.00 1,560.40
03/28/2024 Michelle 00220 INTRAORAL-PERIAPICAL FIRST FILM 0.00 1,560.40
03/28/2024 Michelle 00230 INTRAORAL-PERIAPICAL-EACH ADDITIONAL FIL 0.00 1,560.40

03/28/2024 Michelle 00230 INTRAORAL-PERIAPICAL-EACH ADDITIONAL FIL 0.00 1,560.40

03/28/2024 Michelle D0180 comprehensive periodontal evaluation - new or 140.00 1,700.40

established patient
03/28/2024 Michelle D0274 bitewings - four radiographic images 86.00 1,786.40
03/28/2024 Michelle F5000 FluoriMax 5000 1.1% 15.00 1,801.40
03/28/2024 Michelle Pay Cash $75.00 - Prepayment 75.00 1,726.40
 Date Patient Code Tooth Description Charges Credits Balance
03/28/2024 Michelle Claim Pri Claim $226.00 Sun Life Financial
Received 04/25/2024
NO PAYMENT
03/28/2024 Michelle Claim Pri Claim $226.00 METLIFE*
Received 05/14/2024
Payment: $59.00
03/28/2024 Michelle Stmt Statement-InPerson
04/10/2024 Michelle D4346 scaling in presence of generalized moderate or 232.00 1,958.40
severe gingival inflammation – full mouth, after oral
evaluation
04/10/2024 Michelle M1208 No Ins or coverage- TOPICAL FLUORIDE 24.00 1,982.40
04/10/2024 Michelle Pay Credit Card $163.20 - Prepayment 163.20 1,819.20
04/10/2024 Michelle Claim Pri Claim $232.00 Sun Life Financial
Received 04/25/2024
NO PAYMENT
04/10/2024 Michelle Claim Pri Claim $232.00 METLIFE*
Received 05/14/2024
Payment: $60.00
04/10/2024 Michelle Stmt Statement-InPerson
04/23/2024 Michelle Txfr 0.00 1,819.20
04/23/2024 Michelle Txfr 0.00 1,819.20
04/23/2024 Michelle Txfr 0.00 1,819.20
04/23/2024 Michelle Txfr 0.00 1,819.20
04/23/2024 Michelle Txfr 0.00 1,819.20
04/25/2024 Michelle Txfr 0.00 1,819.20
05/13/2024 Michelle InsPay Insurance Payment for Claim 11/02/2023 310.20 1,509.00
05/14/2024 Michelle Txfr 0.00 1,509.00
05/14/2024 Michelle InsPay Insurance Payment for Claim 04/10/2024 60.00 1,449.00
05/14/2024 Michelle InsPay Insurance Payment for Claim 03/28/2024 59.00 1,390.00
07/03/2024 Michelle Txfr 0.00 1,390.00
10/01/2024 Michelle D9310 consultation - diagnostic service provided by dentist 0.00 1,390.00
or physician other than requesting dentist or
physician
10/01/2024 Michelle D9987 cancelled appointment 0.00 1,390.00
03/18/2025 Michelle Stmt Statement-Mail
04/14/2025 Michelle Stmt Statement-Mail
05/06/2025 Michelle Stmt Statement-Mail
05/12/2025 Michelle Pay Credit Card $1,390.00 1,390.00 0.00