Modern Dentistry of Jupiter
Dr. Holovnia’s VIP Insurance Plan
Periodontal yearly membership with four periodontal maintenance cleanings, preventive diagnostics, annual savings, and a larger courtesy discount on needed dental treatment.
Periodontal Yearly Enrollment Fee$872
Each Additional Family Member$747
Included in Membership Plan
- 4 periodontal maintenance cleanings per year ($838.80 savings)
- 1 comprehensive oral exam per year ($155.70 savings)
- 1 routine examination per year ($92.80 savings)
- 2 limited/problem-focused exams per year ($303.40 savings)
- 2 cavity-detecting series of X-rays ($444.40 savings)
- 2 fluoride applications per year ($61.20 savings)
- 1 CBCT scan per year ($365.90 savings)
- 1 panoramic X-ray or full mouth series X-rays per year ($199.10 savings)
Total savings: $2,461.30 per year
Plus 20% Courtesy Discount
20%
Members receive a courtesy discount on needed dental treatment within the benefit year. The discount does not apply to orthodontic treatment.
20% Discounted Treatment & Services
| Service | Cash Fee | VIP Fee | Savings |
|---|---|---|---|
| In-Office Whitening | $625.90 | $399.00 | $226.90 |
| Occlusal Guard | $716.00 | $593.00 | $123.00 |
| One Surface Filling | $276.00 | $220.80 | $55.20 |
| Two Surface Filling | $356.20 | $284.96 | $71.24 |
| Three Surface Filling | $431.00 | $344.80 | $86.20 |
| Four Surface Filling | $503.70 | $402.96 | $100.74 |
| Porcelain Crown | $1,789.20 | $1,431.36 | $357.84 |
Patient Name
Date
Patient Signature
Date
Effective Date: ________________________________________________
Non-transferable. No refunds issued. All benefits of your VIP Membership Plan must be used within your benefit year.