Quotation Estimate Orthodontist in United States New York City –Free Word Template Download with AI
Orthodontic Treatment Services — United States New York City
Manhattan Orthodontic Center452 Park Avenue, Suite 1200
New York, NY 10022
United States
Tel: (212) 555-0187
Email: [email protected]
NYS License No. ORTH-2019-44782 Prepared For:
Patient Name: Jordan A. Mitchell
Address: 88 West 34th Street, Apt 5B
New York, NY 10001
United States
Tel: (917) 555-3342
Insurance: Aetna Dental PPO (ID: AET-7782910)
This Quotation Estimate has been prepared by our orthodontist team at Manhattan Orthodontic Center, located in the heart of United States New York City, following a comprehensive clinical examination and digital imaging assessment conducted on June 5, 2025. The following line items represent the projected cost of your complete orthodontic treatment plan. All pricing reflects current 2025 New York City orthodontic fee schedules and is subject to the terms outlined below.
| Item No. | Description of Orthodontic Service | Frequency | Unit Cost (USD) | Estimated Total (USD) |
|---|---|---|---|---|
| 01 | Initial Consultation & Comprehensive Diagnostic Records (Panoramic X-ray, Cephalometric X-ray, Intraoral Photos, Digital Impressions) | One-time | $450.00 | $450.00 |
| 02 | Custom Orthodontic Treatment Plan Design & Digital Simulation (3D Smile Preview) | One-time | $325.00 | $325.00 |
| 03 | Placement of Self-Ligating Ceramic Braces (Upper & Lower Arch, 28 brackets total) | One-time | $4,800.00 | $4,800.00 |
| 04 | Monthly Orthodontic Adjustment Visits (Wire changes, elastic replacements, progress monitoring) | 18 months | $275.00 | $4,950.00 |
| 05 | Interproximal Reduction (IPR) — Selective Enamel Reduction for Space Creation | As needed (est. 3 sessions) | $180.00 | $540.00 |
| 06 | Removable Retainer Fabrication (Hawley Retainer — Upper & Lower) | One-time | $650.00 | $650.00 |
| 07 | Fixed Lingual Retainer Bonding (Lower Anterior Segment) | One-time | $425.00 | $425.00 |
| 08 | Post-Treatment Follow-Up & Retainer Adjustments (Year 1 & Year 2) | 4 visits | $150.00 | $600.00 |
| 09 | Emergency Orthodontic Appointment (Broken bracket, wire irritation — included) | Included | $0.00 | $0.00 |
| Subtotal (All Orthodontic Services) | $12,740.00 |
| Estimated Insurance Adjustment (Aetna PPO — 50% orthodontic benefit) | -$6,370.00 |
| NYC Sales Tax (8.875% on applicable items) | $565.28 |
| Patient Estimated Responsibility | $6,935.28 |
Manhattan Orthodontic Center, as a licensed orthodontist practice in United States New York City, offers the following payment structures for this Quotation Estimate:
- Full Payment at Placement: 5% discount applied to the patient responsibility total (savings of $346.76).
- Monthly Installment Plan: 24 equal monthly payments of $288.97 with no interest, beginning one month after brace placement.
- Third-Party Financing (CareCredit / Sunbit): 0% APR for 12 months or 6.99% APR for 24–60 months, subject to credit approval.
- Health Savings Account (HSA) / Flexible Spending Account (FSA): All orthodontic services listed in this Quotation Estimate are eligible for HSA/FSA reimbursement under IRS Section 213(d).
- This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After the expiration date, the orthodontist practice reserves the right to revise pricing in accordance with updated New York City fee schedules.
- Insurance estimates are based on the patient's current Aetna Dental PPO plan benefits as of June 2025. The practice will submit all claims directly to the insurer, but the patient remains ultimately responsible for any balance not covered by the insurance carrier.
- The treatment timeline of approximately eighteen (18) months is an estimate. The orthodontist may adjust the duration based on clinical progress, patient compliance with elastics and oral hygiene, and any unforeseen complications.
- Should the patient discontinue treatment before completion, a pro-rated fee for remaining scheduled visits will not be charged; however, the cost of already-placed appliances and completed services is non-refundable.
- All services are performed in compliance with the New York State Education Law (Article 139) and the regulations of the New York State Board for Professional Practice in the Healing Arts.
- This Quotation Estimate does not include the cost of any pre-existing dental restorations (fillings, crowns, root canals) that may need to be addressed prior to orthodontic treatment. A separate estimate will be provided if such services are required.
- By signing below, the patient acknowledges receipt of this Quotation Estimate and agrees to the terms stated herein. Signature does not obligate the patient to proceed with treatment but confirms understanding of the projected costs.
Jordan A. Mitchell Orthodontist / Authorized Representative
Dr. Elena Vasquez, DDS, MS ⬇️ Download as DOCX Edit online as DOCX
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