Quotation Estimate Dentist in United States New York City –Free Word Template Download with AI
Manhattan Comprehensive Dental Care — Licensed Dentist Practice
Serving the United States New York City Metropolitan Area
Dentist Practice Information
Practice Name: Manhattan Comprehensive Dental Care
Lead Dentist: Dr. Eleanor Whitfield, DDS, FICOI
NY State Dental License: #D-4829173
Address: 1420 Lexington Avenue, Suite 800
City, State, ZIP: United States New York City, NY 10028
Phone: (212) 555-0187
Email: [email protected]
Client / Patient Information
Patient Name: Mr. Jonathan R. Caldwell
Insurance Provider: Aetna Dental PPO
Policy Number: AET-7742-9931
Address: 88 West 34th Street, Apt 12B
City, State, ZIP: United States New York City, NY 10001
Phone: (917) 555-0342
Date of Birth: 03/14/1981
This Quotation Estimate has been prepared by our licensed Dentist team at Manhattan Comprehensive Dental Care, located in the heart of the United States New York City, following a comprehensive diagnostic examination and digital radiographic assessment conducted on June 10, 2025. The following line items represent the projected costs for the recommended course of dental treatment. All pricing reflects current 2025 fee schedules for dental services rendered in the United States New York City market and are subject to the terms outlined below.
| Item # | Dental Procedure / Service | ADA Code | Qty | Unit Price (USD) | Subtotal (USD) |
|---|---|---|---|---|---|
| 1 | Comprehensive Periodontal Scaling & Root Planing (Full Mouth, 4 Quadrants) | D4346 | 4 | $385.00 | $1,540.00 |
| 2 | Porcelain Crown — Upper Right First Molar (Tooth #3) | D2740 | 1 | $1,850.00 | $1,850.00 |
| 3 | Composite Resin Filling — Lower Left Second Premolar (Tooth #20) | D2392 | 1 | $320.00 | $320.00 |
| 4 | Professional Dental Cleaning & Polishing (Prophylaxis) | D1110 | 1 | $185.00 | $185.00 |
| 5 | Full-Mouth Digital Panoramic X-Ray & Bitewing Radiographs (4 views) | D0333 / D0210 | 1 | $210.00 | $210.00 |
| 6 | Oral Cancer Screening & Comprehensive Diagnostic Consultation | D0120 | 1 | $150.00 | $150.00 |
| 7 | Fluoride Varnish Application (Adult) | D1206 | 1 | $75.00 | $75.00 |
| 8 | Emergency Dental Visit Fee (if required within treatment window) | D0010 | 1 | $120.00 | $120.00 |
| Subtotal (All Procedures): | $4,450.00 |
| Estimated Insurance Adjustment (Aetna PPO): | -$1,620.00 |
| NY State Sales Tax (Applicable Materials): | $89.00 |
| Patient Responsibility / Grand Total: | $2,919.00 |
- This Quotation Estimate is valid for thirty (30) calendar days from the date of issuance. After the expiration date, the Dentist practice reserves the right to revise pricing due to changes in material costs, supply chain adjustments, or updated United States New York City municipal fee regulations.
- All dental services listed in this Quotation Estimate will be performed by Dr. Eleanor Whitfield or a duly licensed associate Dentist at our United States New York City practice facility. No services will be delegated to unlicensed personnel.
- The estimated insurance adjustment is based on the current Aetna Dental PPO benefit schedule. Final reimbursement amounts are determined solely by the insurance carrier and may vary. The patient is responsible for any difference between the estimated and actual insurance payment.
- A non-refundable deposit of twenty-five percent (25%) of the patient-responsibility total ($729.75) is required to schedule the first treatment appointment. The remaining balance is due at the conclusion of each treatment visit.
- Payment may be made via credit card (Visa, Mastercard, American Express), ACH bank transfer, or HSA/FSA card. A convenience fee of 2.9% applies to credit card transactions as mandated by United States New York City financial processing regulations.
- Any additional procedures identified during active treatment that were not included in this Quotation Estimate will require a separate written authorization and updated Quotation Estimate before commencement of work.
- This Quotation Estimate does not constitute a guarantee of specific clinical outcomes. The Dentist will exercise reasonable professional judgment in performing all recommended procedures in accordance with the American Dental Association (ADA) standards of care.
- All patient records, radiographic images, and treatment documentation generated in connection with this Quotation Estimate are maintained in compliance with HIPAA regulations and New York State Public Health Law Article 27-F.
- By signing below, the patient acknowledges receipt of this Quotation Estimate and authorizes the Dentist practice to proceed with the listed dental services upon deposit payment. This document does not obligate the patient to complete all listed procedures; however, cancellation of scheduled appointments within forty-eight (48) hours will incur a $100.00 no-show fee.
Patient Signature — Mr. Jonathan R. Caldwell
Date: ____________________
Dentist / Authorized Representative — Dr. Eleanor Whitfield, DDS
Manhattan Comprehensive Dental Care, United States New York City
Date: ____________________
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