Quotation Estimate Dentist in United States Chicago –Free Word Template Download with AI
2145 N. Lakeview Avenue, Suite 300, Chicago, Illinois 60614, United States
Phone: (312) 555-0187 | Email: [email protected]
IL Dental License No. 17.0987654 | NPI: 1234567890
Quotation EstimateQuotation Estimate Details
Document No.: QE-2025-07842
Date Issued: June 12, 2025
Valid Until: July 12, 2025
Prepared By: Dr. Margaret Chen, DDS
Patient Information
Name: Jonathan R. Whitfield
Address: 847 W. Diversey Pkwy, Chicago, IL 60614
Insurance: Aetna PPO (Member #AET-448291)
Phone: (773) 555-0234
This Quotation Estimate has been prepared by Lakeview Dental Associates, a licensed and fully accredited dental practice located in Chicago, Illinois, United States, to provide the patient with a comprehensive, itemized breakdown of anticipated costs for the recommended course of dental treatment. As a Dentist operating within the United States Chicago metropolitan area, our office adheres to the fee schedules established by the Illinois Dental Association and the American Dental Association. This Quotation Estimate is a good-faith projection of charges and does not constitute a binding contract. Final billing may vary based on the extent of treatment required during the actual procedure, any unforeseen complications, or changes in the patient's insurance coverage during the treatment period.
Following a thorough clinical examination, diagnostic imaging (including a full panoramic X-ray and intraoral periapical radiographs), and periodontal assessment conducted on June 5, 2025, the undersigned Dentist has recommended the following treatment plan. All pricing reflects the standard professional fees charged by this dental practice in the United States Chicago region for the calendar year 2025.
| Item No. | Procedure / Service Description | ADA Code | Estimated Fee (USD) | Est. Insurance Adjustment | Patient Responsibility |
|---|---|---|---|---|---|
| 1 | Comprehensive Periodontal Scaling and Root Planing (all four quadrants) | D4348 | $1,240.00 | ($744.00) | $496.00 |
| 2 | Composite Resin Restorations – Moderate (2 teeth, upper right) | D2392 | $580.00 | ($348.00) | $232.00 |
| 3 | Porcelain Crown – Molar (lower left, tooth #19) | D2740 | $1,850.00 | ($925.00) | $925.00 |
| 4 | Endodontic Therapy (Root Canal) – Molar (upper left, tooth #14) | D3310 | $1,420.00 | ($852.00) | $568.00 |
| 5 | Prophylaxis / Routine Cleaning (post-treatment maintenance) | D1110 | $185.00 | ($111.00) | $74.00 |
| 6 | Diagnostic Imaging – Panoramic X-ray and 4 Periapicals | D0330 / D0147 | $210.00 | ($126.00) | $84.00 |
| 7 | Local Anesthesia and Sedation (Nitrous Oxide) – per procedure | D0010 / D9910 | $95.00 | ($57.00) | $38.00 |
| 8 | Emergency / Follow-up Visit (estimated, if required) | D0140 | $120.00 | ($72.00) | $48.00 |
| TOTAL ESTIMATED FEES | $5,700.00 | ($3,435.00) | $2,265.00 | ||
The following terms govern this Quotation Estimate issued by our dental practice in Chicago, United States:
1. Validity Period: This Quotation Estimate remains valid for thirty (30) calendar days from the date of issuance. After this period, fees may be subject to revision in accordance with the annual fee schedule adjustments adopted by the Chicago Dental Society and the broader United States dental community.
2. Payment Schedule: The patient is requested to provide a deposit of twenty-five percent (25%) of the total patient responsibility amount at the time of treatment scheduling. The remaining balance is due at the conclusion of each individual treatment visit. Lakeview Dental Associates accepts all major credit cards, HSA/FSA cards, and direct insurance billing. A 1.5% monthly finance charge will apply to any balance outstanding beyond thirty days.
3. Insurance Coordination: While this Quotation Estimate includes estimated insurance adjustments based on the patient's current Aetna PPO plan, the final reimbursement amount is determined solely by the insurance carrier. The patient remains financially responsible for any difference between the estimated adjustment and the actual payment. Our office in Chicago, Illinois, will submit all claims electronically on the patient's behalf.
4. Scope of Treatment: This Quotation Estimate reflects the clinical findings as of the examination date. Should the Dentist discover additional pathology during the course of treatment (e.g., hidden decay, additional periodontal pockets, or the need for a post-and-core prior to crown placement), a supplemental Quotation Estimate will be provided and must be approved in writing by the patient before any additional work commences.
5. Cancellation Policy: Appointments cancelled with less than forty-eight (48) hours' notice will be subject to a $75.00 administrative fee, consistent with standard practice among dental offices throughout the United States Chicago area.
6. Warranties: All restorative work (crowns, composite fillings) is covered under a two-year workmanship warranty. Porcelain crowns carry a five-year warranty against fracture under normal function. Warranties are void in the event of trauma, bruxism without a protective night guard, or failure to attend scheduled maintenance cleanings.
Important Note to Patient: This Quotation Estimate is provided for informational and planning purposes only. It is not a guarantee of final charges. As a licensed Dentist practicing in the United States Chicago jurisdiction, Dr. Chen is bound by the Illinois Dental Practice Act (225 ILCS 60) and the ethical standards of the American Dental Association. The patient is encouraged to review this document carefully and to contact our office at (312) 555-0187 with any questions or to request a revised estimate.By signing below, the patient acknowledges receipt of this Quotation Estimate, confirms understanding of the recommended treatment plan, and authorizes Lakeview Dental Associates to proceed with the outlined procedures in Chicago, Illinois, United States. The patient further authorizes the release of relevant dental records to the insurance carrier for the purpose of claim processing.
Patient Signature & DateJonathan R. Whitfield
Dentist / Authorized RepresentativeDr. Margaret Chen, DDS
Lakeview Dental Associates
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