Quotation Estimate Ophthalmologist in United States Los Angeles –Free Word Template Download with AI

Quotation Estimate No.: QE-2025-04872 Date Issued: June 12, 2025 Valid Until: July 12, 2025 (30 days) Prepared By: Dr. Margaret Chen, MD, FACS

Patient Name: Jonathan R. Whitfield	Date of Birth: March 14, 1971
Address: 2847 Sunset Blvd, Los Angeles, CA 90026, United States	Phone: (310) 555-4421
Insurance Provider: UnitedHealthcare Vision Plus	Policy No.: UHC-VIS-9928471

This Quotation Estimate has been prepared by our board-certified Ophthalmologist team at Westside Vision & Ophthalmology Center, located in the heart of United States Los Angeles, to provide a comprehensive and transparent breakdown of anticipated costs for the following ophthalmic diagnostic and therapeutic procedures. This document serves as a formal Quotation Estimate for the patient and their insurance carrier, and all pricing reflects current 2025 fee schedules applicable to the United States Los Angeles metropolitan medical market.

Item No.	Description of Ophthalmologist Service	CPT Code	Qty	Unit Price (USD)	Extended Price (USD)
001	Comprehensive Ophthalmologist Consultation & Dilated Eye Examination (initial visit, including medical history review, visual acuity testing, and slit-lamp biomicroscopy)	92014	1	$385.00	$385.00
002	Optical Coherence Tomography (OCT) of the Macula & Retinal Nerve Fiber Layer (bilateral)	92134	2	$210.00	$420.00
003	Automated Refraction & Keratometry (bilateral, including corneal topography mapping)	92310	2	$95.00	$190.00
004	Fluorescein Fundus Photography & Wide-Field Retinal Imaging (bilateral, 45-degree field)	92236	2	$145.00	$290.00
005	Anterior Segment Ultrasound (B-Scan) – Right Eye (for evaluation of suspected anterior chamber pathology)	92130	1	$175.00	$175.00
006	Intraocular Pressure Measurement via Goldmann Applanation Tonometry (bilateral, with corneal thickness adjustment)	92130	2	$45.00	$90.00
007	Visual Field Testing – Humphrey 24-2 Standard Threshold (bilateral, for glaucoma surveillance)	92082	2	$165.00	$330.00
008	Prescription of Custom Bifocal Contact Lenses (bilateral, including fitting, trial, and one follow-up adjustment visit by the Ophthalmologist)	92310	1	$620.00	$620.00
009	Follow-up Ophthalmologist Visit (4-week post-procedure evaluation, including re-examination and treatment plan revision)	99213	1	$225.00	$225.00
010	Prescription Medications – Topical Anti-inflammatory Eye Drops (Loteprednol 0.5%, 30-day supply, bilateral)	N/A	2	$58.00	$116.00

Subtotal (All Ophthalmologist Services)	$3,241.00
Estimated Insurance Adjustment (UHC-VIS-9928471)	-$1,872.60
Patient Copay / Coinsurance (20%)	$275.78
California State Sales Tax (7.25% on non-covered items)	$45.12
Estimated Patient Responsibility (Grand Total)	$320.90

This Quotation Estimate is valid for a period of thirty (30) calendar days from the date of issuance. After the expiration date, all pricing for the Ophthalmologist services listed herein is subject to revision in accordance with updated fee schedules in the United States Los Angeles region.
All services described in this Quotation Estimate will be performed by or under the direct supervision of a board-certified Ophthalmologist licensed by the California Medical Board. The attending physician for this case is Dr. Margaret Chen, MD, FACS, who holds over fifteen years of clinical experience in comprehensive ophthalmology.
Insurance estimates are provided as good-faith projections based on the current benefit structure of the patient's plan. The final amount billed to the patient may vary depending on prior authorization status, deductible fulfillment, and any changes in coverage effective during the treatment period. Westside Vision & Ophthalmology Center is not responsible for insurance denials or coverage changes.
Payment for the patient's estimated responsibility is due at the time of service or within fourteen (14) days of the final invoice. A 1.5% monthly late fee will be applied to any balance remaining unpaid after the due date, in compliance with California Civil Code Section 1617.
This Quotation Estimate does not constitute a guarantee of medical outcomes. The Ophthalmologist reserves the right to modify the treatment plan based on clinical findings during the examination. Any additional procedures identified during the visit will be communicated to the patient prior to implementation, and a supplemental Quotation Estimate will be provided if additional costs are anticipated.
All medical records, imaging data, and diagnostic reports generated during the course of treatment are the property of the patient and may be released to the patient or their designated representative in accordance with HIPAA regulations and California Confidentiality of Medical Information Act (CMIA).
This Quotation Estimate is governed by the laws of the State of California, United States. Any disputes arising from the services described herein shall be subject to the exclusive jurisdiction of the courts located in Los Angeles County, United States Los Angeles.
Westside Vision & Ophthalmology Center maintains comprehensive malpractice and professional liability insurance coverage in the amount of $5,000,000 per occurrence, satisfying all requirements set forth by the California Medical Board for Ophthalmologist practitioners operating in the United States Los Angeles metropolitan area.

By signing below, the patient (or authorized representative) acknowledges receipt of this Quotation Estimate and authorizes the Ophthalmologist at Westside Vision & Ophthalmology Center to proceed with the services described herein. The patient confirms that they have had the opportunity to review all line items, understand the estimated costs, and ask questions regarding the scope of care in the United States Los Angeles facility.

Patient / Authorized Representative:

Jonathan R. Whitfield | Date: _______________

Attending Ophthalmologist:

Dr. Margaret Chen, MD, FACS | Date: _______________ ⬇️ Download as DOCX Edit online as DOCX

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