Is there a contractual adjustment in this EOB?

Explanation of Benefits (EOB) Statement Please do not use or disclose the information contained here for any purposes other than ones permitted under HIPAA. Back Print File Ref. Number: 2061130437 99 Provider Control Number: Status: PROCESSED on 06/12/2012 Claim Source: CPS Claim Year: 2012 Rendered by: DR. BEKKI PATTON Location of Service: OFFICE Patient Name: nxxxmrx Relationship to Subscriber: Self Subscriber Name: SSN or Identification Number: RNXTXX Group Number: 120731 Provider ID: PDP Fee (if a licable $3s.oo $13.00 $48.00 xxxxX62SS Date of Service /30/2012 Service 00th Description / Area Code LIMITED ORAL EVALUATION 00140 INTRAORAL Fee ha $60.00 $24.00 $84.00 uctibl Applied Plan Notes xpen $35.00 $13.00 $48.00 enefi $3s.oo $13.00 J /30/2012 PERIAPICAL FILM 00220 Tota I Payment Dat Payment 06/13/2012 Detail Payment 06/13/2012 Detail Total $0.00 $48.00 Benefit Paid $10.00 Payee TRACY SPIKER Cycle Date 06/13/2012 Payment Method CHK EFT Check Number or Trace 005501881 007069185 Provider of $38.00 06/13/2012 Service $48.00 * Trace ID identifies Electronic Payments. As of 06/12/2012, $359.00 has been applied toward the plan maximum of $10,000.00.