Quotation Estimate Surgeon in United States Los Angeles –Free Word Template Download with AI
Professional Surgical Services — Los Angeles, California, United States
Ref: QE-LA-2025-04872 | Valid Until: July 15, 2025
SURGEON INFORMATION & CREDENTIALS| Field | Details |
|---|---|
| Lead Surgeon | Dr. Margaret E. Callahan, MD, FACS — Board-Certified General & Minimally Invasive Surgeon |
| Medical License | California Medical Board License No. A-3847291 (Active, United States) |
| Board Certification | American Board of Surgery; American Board of Minimally Invasive Surgery |
| Years of Experience | 22 years of surgical practice, with over 4,200 procedures performed in the Los Angeles metropolitan area |
| Hospital Affiliation | Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, United States |
| Specialization | Laparoscopic Cholecystectomy, Advanced Abdominal Surgery, Bariatric Procedures |
| # | Service / Procedure | CPT Code | Qty | Unit Price (USD) | Subtotal (USD) |
|---|---|---|---|---|---|
| 1 | Pre-operative Consultation & Physical Examination by Lead Surgeon | 99204 | 1 | $485.00 | $485.00 |
| 2 | Comprehensive Pre-operative Laboratory Panel (CBC, CMP, Coagulation, Type & Screen) | 80053 | 1 | $312.00 | $312.00 |
| 3 | Pre-operative Cardiac Clearance & ECG (Los Angeles Cardiology Associates) | 93000 | 1 | $225.00 | $225.00 |
| 4 | Laparoscopic Cholecystectomy — Primary Procedure (Surgeon Fee) | 47562 | 1 | $8,750.00 | $8,750.00 |
| 5 | Anesthesia Services — General Anesthesia (Anesthesiologist Fee) | 00812 | 1 | $2,340.00 | $2,340.00 |
| 6 | Operating Room Facility Fee (Cedars-Sinai, Los Angeles, United States) | 99977 | 1 | $4,120.00 | $4,120.00 |
| 7 | Surgical Supplies, Implants & Disposables (Trocars, Sutures, Drains) | N/A | 1 | $1,890.00 | $1,890.00 |
| 8 | Post-operative Hospital Stay — 2 Nights (Private Room, Los Angeles) | 99221-99223 | 2 | $3,450.00 | $6,900.00 |
| 9 | Post-operative Pathology & Tissue Analysis (Gallbladder Specimen) | 88305 | 1 | $425.00 | $425.00 |
| 10 | Post-operative Follow-up Visit with Surgeon (Week 2 & Week 6) | 99214 | 2 | $310.00 | $620.00 |
| 11 | Prescription Medications & Wound Care Supplies (30-day supply) | N/A | 1 | $285.00 | $285.00 |
| GRAND TOTAL ESTIMATE (USD) | $26,752.00 | ||||
- This Quotation Estimate is valid for a period of sixty (60) calendar days from the date of issue. After this period, pricing for surgical services in Los Angeles, United States, may be subject to revision based on facility fee adjustments, supply costs, and prevailing medical billing standards.
- The Surgeon named in this document, Dr. Margaret E. Callahan, is the designated principal operator. In the event of an unforeseen medical emergency requiring substitution, a surgeon of equivalent or superior board certification will be assigned, and the patient or their authorized representative will be notified in writing within twenty-four (24) hours.
- All surgical procedures referenced in this Quotation Estimate will be performed at Cedars-Sinai Medical Center, located in Los Angeles, California, United States, in compliance with all federal, state, and local medical regulations governing surgical practice in the United States.
- Payment terms: A deposit of twenty-five percent (25%) of the total estimated amount, amounting to $6,688.00 USD, is due upon acceptance of this Quotation Estimate. The remaining balance is due within thirty (30) days following the completion of all post-operative follow-up visits.
- This estimate is a good-faith projection and does not constitute a binding contract for medical services. Actual charges may vary based on the complexity of the procedure, intraoperative findings, and the specific needs of the patient during the surgical event.
- All services are subject to the standard terms of the patient agreement executed at the time of admission at the Los Angeles facility. The patient acknowledges that surgical procedures carry inherent risks, and informed consent will be obtained prior to any operative intervention.
- This Quotation Estimate is governed by the laws of the State of California and the federal laws of the United States of America. Any disputes arising from this estimate shall be resolved in the courts of Los Angeles County, California.
- Confidentiality: All medical information contained in or related to this Quotation Estimate is protected under the Health Insurance Portability and Accountability Act (HIPAA) of the United States and shall not be disclosed without the patient's written consent.
By signing below, the patient or authorized representative acknowledges receipt of this Quotation Estimate for surgical services in Los Angeles, United States, and agrees to the terms and conditions outlined herein. This signature does not constitute a final commitment to surgery but authorizes the medical team to proceed with pre-operative scheduling and preparation.
Patient / Authorized RepresentativeName: ______________________________
Date: ______________________________ Lead Surgeon / Medical Director
Name: Dr. Margaret E. Callahan, MD, FACS
Date: ______________________________
Pacific Coast Surgical Associates — Los Angeles, California, United States — Quotation Estimate Ref: QE-LA-2025-04872
This document is a professional estimate for surgical services and is not a guarantee of medical outcomes. All procedures are subject to the Surgeon's clinical judgment.
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