Quotation Estimate Orthodontist in United States Los Angeles –Free Word Template Download with AI
Orthodontic Treatment Services — United States Los Angeles
Document Reference: QE-2025-LA-0847 | Date Issued: June 15, 2025 | Valid Until: July 15, 2025
Westside Orthodontic Associates4820 Wilshire Boulevard, Suite 310
Los Angeles, California 90036
United States
Phone: (310) 555-0192
Email: [email protected] Prepared For:
Patient: Jordan M. Whitfield
DOB: 03/22/2001
Address: 1247 Sunset Blvd, Apt 5B
Los Angeles, CA 90026
United States
Insurance: Aetna PPO #AET-7742-881
This Quotation Estimate has been prepared by our licensed Orthodontist, Dr. Elena Vasquez, DMD, MS, to provide a comprehensive and transparent financial overview of the recommended orthodontic treatment plan for the patient listed above. As a practice located in the heart of United States Los Angeles, we are committed to delivering world-class orthodontic care while ensuring full financial transparency for every patient. This document serves as a formal Quotation Estimate and does not constitute a binding contract until accepted in writing by the patient. All pricing reflects current 2025 rates for orthodontic services in the Los Angeles metropolitan area.
Following a comprehensive diagnostic evaluation conducted on June 10, 2025, our Orthodontist identified the following conditions requiring treatment: Class II malocclusion with 4mm overjet, moderate crowding in the mandibular arch (approximately 6mm), and a slight crossbite on the left posterior segment. The recommended treatment approach involves fixed orthodontic appliances combined with targeted extractions. The estimated total treatment duration is 24 to 30 months, with bi-weekly adjustment appointments at our Los Angeles clinic.
| Service / Item | Description | Qty | Unit Price (USD) | Subtotal (USD) |
|---|---|---|---|---|
| Initial Diagnostic Workup | Comprehensive exam, panoramic X-ray, cephalometric radiograph, intraoral photographs, digital 3D scan, and treatment planning by the Orthodontist | 1 | $485.00 | $485.00 |
| Extractions (4 premolars) | Removal of teeth #4, #5, #12, #13 under local anesthesia, including post-operative instructions and one follow-up visit | 4 | $320.00 | $1,280.00 |
| Fixed Orthodontic Appliances | Full-arch ceramic (clear) brackets and archwires, bonded to all 28 teeth, including initial placement and all monthly adjustments | 1 | $6,800.00 | $6,800.00 |
| Interproximal Reduction (IPR) | Selective enamel stripping to create space in the mandibular arch, performed by the Orthodontist during adjustment visits | 1 | $450.00 | $450.00 |
| Elastics and Auxiliary Appliances | Monthly supply of Class II elastics, power chains, and any necessary auxiliary springs throughout treatment | 26 | $35.00 | $910.00 |
| Retainers (Post-Treatment) | Two sets of custom-fabricated clear vacuum-formed retainers (upper and lower) plus one set of bonded lingual retainers | 1 | $650.00 | $650.00 |
| Emergency / Breakage Visits | Up to 4 unplanned visits for bracket debonding, wire adjustment, or appliance repair during the treatment period | 4 | $125.00 | $500.00 |
| Final Records and Discharge | Post-treatment radiographs, photographs, digital records, and final consultation with the Orthodontist | 1 | $275.00 | $275.00 |
| TOTAL ESTIMATED COST (Before Insurance) | $11,350.00 | |||
| Estimated Insurance Reimbursement (Aetna PPO, 50% orthodontic benefit) | -$5,675.00 | |||
| PATIENT RESPONSIBILITY (Estimated) | $5,675.00 | |||
As a patient-centered Orthodontist practice in United States Los Angeles, we offer flexible payment arrangements to make this Quotation Estimate accessible. Options include: (a) Full payment at the time of appliance placement with a 3% discount, reducing the patient responsibility to $5,504.75; (b) A 24-month in-house interest-free installment plan of $236.46 per month; (c) Third-party financing through CareCredit or Sunbit with terms ranging from 6 to 60 months; or (d) A 20% down payment at the start of treatment with the balance spread over the remaining treatment months. All payment plans are subject to credit approval.
- This Quotation Estimate is valid for 30 calendar days from the date of issue. After expiration, pricing may be adjusted to reflect current material costs and fee schedules in the Los Angeles orthodontic market.
- The total treatment cost may vary by up to 10% depending on clinical progress, additional procedures the Orthodontist may deem necessary, or changes in the treatment plan.
- Insurance reimbursement is an estimate based on current Aetna PPO orthodontic benefit terms. The patient is responsible for any deductibles, co-pays, or amounts exceeding the plan's lifetime orthodontic maximum.
- Missed appointments exceeding 15 minutes may incur a $75.00 late fee. Three consecutive missed appointments may result in treatment termination at the Orthodontist's discretion.
- This Quotation Estimate does not include general dental services such as fillings, periodontal treatment, or oral surgery beyond the specified extractions.
- All services will be performed or directly supervised by a board-certified Orthodontist at our clinic located in Los Angeles, California, United States.
- By signing below, the patient acknowledges receipt of this Quotation Estimate and agrees to the terms outlined herein. This does not obligate the patient to begin treatment immediately.
Board-Certified Orthodontist
Westside Orthodontic Associates Patient / Authorized Guardian
Jordan M. Whitfield
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