Quotation Estimate Ophthalmologist in United States New York City –Free Word Template Download with AI
245 Park Avenue, Suite 1800, New York City, New York 10167, United States
Phone: (212) 555-0147 | Fax: (212) 555-0148 | Email: [email protected]
NY State Licensed Ophthalmologist Medicare & Medicaid Accepted
Quotation EstimateQuotation Details
Quotation No.: QTE-2025-0718-NYC
Date of Issue: July 18, 2025
Valid Until: August 17, 2025 (30 days)
Prepared By: Dr. Eleanor M. Whitfield, MD, FACS
Specialty: Comprehensive Ophthalmology
Client / Patient Information
Name: Mr. Jonathan R. Caldwell
Address: 118 West 72nd Street, New York City, NY 10023
Insurance Provider: Aetna Vision Plus (Member ID: AET-4482917)
Referring Physician: Dr. Samuel Okafor, Internal Medicine
Phone: (917) 555-3321
Dear Mr. Caldwell,
Thank you for contacting Manhattan Vision & Ophthalmology Center for a comprehensive ophthalmological evaluation. This Quotation Estimate outlines the anticipated costs for the full scope of ophthalmologist services recommended for your ongoing eye health management in New York City. All pricing reflects current 2025 fee schedules for board-certified ophthalmologist care in the United States, specifically within the New York City metropolitan area. Please review each line item carefully and contact our billing office with any questions regarding this estimate.
| # | Service / Procedure Description | CPT Code | Qty | Unit Price (USD) | Estimated Total (USD) |
|---|---|---|---|---|---|
| 1 | Comprehensive Ophthalmologist Dilated Eye Examination (initial visit, New York City facility fee included) | 92014 | 1 | $385.00 | $385.00 |
| 2 | Optical Coherence Tomography (OCT) – Bilateral Retinal Imaging | 92134 | 2 | $145.00 | $290.00 |
| 3 | Automated Visual Field Testing (Humphrey 24-2) – Bilateral | 92082 | 2 | $110.00 | $220.00 |
| 4 | Anterior Segment Biomicroscopy with Gonioscopy (Ophthalmologist Performed) | 92010 | 1 | $95.00 | $95.00 |
| 5 | Corneal Topography and Pachymetry (Pentacam Analysis) | 92020 | 1 | $175.00 | $175.00 |
| 6 | Phacoemulsification Cataract Surgery with Premium Toric IOL – Right Eye (if indicated) | 66984 | 1 | $4,850.00 | $4,850.00 |
| 7 | Post-Operative Ophthalmologist Follow-Up Visits (3 visits within 30 days) | 99213 | 3 | $185.00 | $555.00 |
| 8 | Prescription for Post-Surgical Ophthalmic Medications (4-week supply) | N/A | 1 | $120.00 | $120.00 |
| 9 | Annual Ophthalmologist Monitoring Visit (subsequent year, New York City practice) | 92014 | 1 | $320.00 | $320.00 |
| SUBTOTAL (Before Insurance Adjustment) | $7,010.00 | ||||
| Estimated Insurance Coverage (Aetna Vision Plus – 80% after deductible) | -$4,807.00 | ||||
| ESTIMATED PATIENT RESPONSIBILITY | $2,203.00 | ||||
Terms and Conditions of This Quotation Estimate
- This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. All ophthalmologist service fees are subject to change in accordance with New York State medical board regulations and the practice's annual fee schedule updates.
- All prices listed are in United States Dollars (USD) and reflect the standard fee schedule for ophthalmologist services rendered at our New York City location. Facility fees, anesthesia fees, and pathology charges are included unless otherwise noted.
- Insurance coverage estimates are based on the current Aetna Vision Plus plan benefits as of the date of this Quotation Estimate. Actual reimbursement may vary depending on deductible status, out-of-network provisions, or plan changes during the treatment period. The patient is responsible for any difference between the estimated and actual insurance adjustment.
- The cataract surgery line item (Item 6) is conditional and will only be billed if the ophthalmologist determines surgical intervention is medically necessary following the comprehensive examination. If surgery is not indicated, this charge will be removed from the final invoice.
- Payment is due within thirty (30) days of the final invoice date. Manhattan Vision & Ophthalmology Center accepts all major credit cards, HSA/FSA cards, and personal checks. A 1.5% monthly late fee will be applied to balances exceeding the payment window.
- 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 will be discussed with the patient prior to implementation and will be subject to a revised Quotation Estimate.
- All ophthalmologist services are performed in compliance with New York State Education Law, Article 139, and the standards set forth by the American Academy of Ophthalmology. Our practice maintains full malpractice insurance coverage through the New York State Medical Society.
- Confidentiality of all patient records and this Quotation Estimate is protected under the Health Insurance Portability and Accountability Act (HIPAA) and New York State Public Health Law, Article 28-F.
- For patients requiring interpreter services or accessibility accommodations at our New York City facility, please contact our patient services desk at least 48 hours in advance. No additional fee will be charged for these services.
Lead Ophthalmologist, Manhattan Vision & Ophthalmology Center
NY Medical License No. 2847193 Patient / Authorized Representative
Signature & Date
Acknowledgment of Quotation Estimate ⬇️ Download as DOCX Edit online as DOCX
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