Quotation Estimate Dentist in United States Miami –Free Word Template Download with AI
2100 Brickell Avenue, Suite 450, Miami, Florida 33131, United States
Phone: (305) 555-0187 | Email: [email protected]
Florida Dental License No. DL-2019-44872
Quotation EstimatePrepared For (Patient)
Name: Maria Elena Rodriguez
Address: 1450 Coral Way, Apt 3B, Miami, FL 33145
Phone: (786) 555-2234
Email: [email protected]
Insurance Provider: Aetna Dental PPO
Policy Number: AET-2024-887341
Quotation Details
Quotation Estimate No.: QTE-2025-00347
Date Issued: June 12, 2025
Valid Until: July 12, 2025
Prepared By: Dr. James A. Whitfield, DDS
Role: Lead Dentist, Miami Dental Care Center
Location: Miami, United States
Dear Ms. Rodriguez,
Thank you for choosing Miami Dental Care Center for your oral health needs. This Quotation Estimate has been prepared following your comprehensive dental examination and diagnostic imaging session conducted on June 10, 2025. Our team of experienced professionals, led by our lead Dentist Dr. James A. Whitfield, has carefully evaluated your dental records, panoramic X-rays, and intraoral photographs to develop this detailed treatment plan and cost estimate. This document serves as your official Quotation Estimate for all recommended procedures to be performed at our Miami, United States facility.
| # | Procedure / Service | CPT Code | Qty | Unit Price (USD) | Subtotal (USD) | Est. Insurance |
|---|---|---|---|---|---|---|
| 1 | Comprehensive Periodontal Scaling & Root Planing (Full Mouth) | D4348 | 1 | $680.00 | $680.00 | 50% |
| 2 | Porcelain Crown – Tooth #14 (Upper Left Second Molar) | D2757 | 1 | $1,450.00 | $1,450.00 | 50% |
| 3 | Composite Resin Filling – Tooth #21 (Upper Right First Molar) | D2392 | 2 | $220.00 | $440.00 | 80% |
| 4 | Professional Dental Cleaning & Polishing (Prophylaxis) | D1110 | 1 | $185.00 | $185.00 | 100% |
| 5 | Full-Mouth Digital X-Ray & Intraoral Photography | D0210 | 1 | $120.00 | $120.00 | 100% |
| 6 | Whitening Treatment – In-Office LED System (Single Session) | D5110 | 1 | $495.00 | $495.00 | 0% |
| 7 | Fluoride Varnish Application (Adult) | D1206 | 1 | $65.00 | $65.00 | 100% |
| 8 | Follow-Up Consultation & Treatment Review (30 min) | D0010 | 1 | $95.00 | $95.00 | 0% |
| Subtotal (All Procedures) | $3,530.00 |
| Estimated Insurance Coverage (Aetna PPO) | -$1,425.00 |
| Patient Responsibility (Before Tax) | $2,105.00 |
| Florida State Sales Tax (6.5%) | $136.83 |
| Estimated Patient Total Due | $2,241.83 |
Terms & Conditions of This Quotation Estimate
- This Quotation Estimate is valid for thirty (30) days from the date of issue. After July 12, 2025, pricing may be subject to adjustment based on material costs, laboratory fees, or changes in our practice's fee schedule in Miami, United States.
- Insurance estimates are provided as a good-faith projection based on your Aetna Dental PPO plan benefits. Actual reimbursement amounts are determined solely by your insurance carrier. Miami Dental Care Center is not responsible for any discrepancy between this estimate and your insurer's final adjudication.
- A deposit of 50% of the estimated patient responsibility is required to schedule and confirm your treatment appointments. The remaining balance is due at the time of service completion.
- Payment plans are available for procedures exceeding $1,000 in patient responsibility. Our office offers in-house financing through CareCredit and Sunbit with terms ranging from 6 to 24 months at 0% APR for qualified applicants.
- All restorative work (crowns, fillings) carries a one-year warranty against material defects when performed by our licensed Dentist team. This warranty does not cover damage from trauma, bruxism, or neglect of oral hygiene.
- Rescheduling or cancellation of appointments must be made at least 48 hours in advance. Late cancellations or no-shows may incur a fee of $75.00, which is not included in this Quotation Estimate.
- This document does not constitute a binding contract. It is an estimate of costs and services. Final charges may vary slightly depending on the complexity encountered during treatment. Our lead Dentist will discuss any material changes with you prior to proceeding.
- Miami Dental Care Center operates in full compliance with all Florida Board of Dentistry regulations, HIPAA privacy standards, and the American Dental Association's ethical guidelines. Our facility is located in the heart of Miami, United States, and is accessible to patients from all surrounding communities including Coral Gables, Brickell, Downtown Miami, and the greater South Florida region.
We are committed to providing you with the highest standard of dental care in the Miami, United States area. Our team of board-certified Dentist professionals, hygienists, and support staff will ensure that every step of your treatment journey is comfortable, transparent, and tailored to your individual needs. Please do not hesitate to contact our office at (305) 555-0187 if you have any questions regarding this Quotation Estimate or would like to discuss alternative treatment options.
Dr. James A. Whitfield, DDSLead Dentist & Practice Owner
Miami Dental Care Center
Date: _______________ Patient Acknowledgment
I have reviewed and understand this Quotation Estimate.
Signature: _________________________
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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