Affinity Group Dental Savings Program

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Sample Fees

Sample Fee Schedule

Sample Savings*

Code	Description	Plan Cost**	Regular Cost**	Savings
0120	Periodic Oral Evaluation	$23	$47	51%
0274	Bitewings-Four Films	$29	$59	51%
1110	Prophylaxis-Adult (light)	$45	$86	48%
1120	Prophylaxis-Child	$32	$63	49%
2160	Amalgam-Three Surface, Primary or Permanent	$95	$197	52%
2750	Crown-Porcelain Fused to High Noble Metal	$577	$1032	44%
3330	Root Canal-Molar (Excluding Final Restoration)	$558	$941	41%
4341	Periodontial Scaling and Root Planning	$119	$237	50%
7140	Extraction-Erupted Tooth or Exposed Root	$74	$156	53%
8080	Comprehensive Orthodontic Treatment of the Adolescent Dentition	20% Discount	$5,443	20%

*These fees represent the CI-5 fee schedule. Normal cost is based on the 80th percentile of the National Dental Advisory Service Comprehensive Fee Report for 2008.

**Prices subject to change

Disclosures:
THIS PLAN IS NOT INSURANCE. THIS IS NOT A MEDICARE PRESCRIPTION DRUG PLAN.*
The plan provides discounts at certain health care providers for medical services. The range of discounts will vary depending on the type of provider and service. The plan does not make payments directly to the providers of medical services. Plan members are obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with the discount medical plan organization. Before purchase, you may access a list of participating health care providers at the Find A Provider page of this web site. Upon request the plan will make available a written list of participating health care providers. You have the right to cancel within the first 30 days after receipt of membership materials and receive a full refund, less a nominal processing fee (nominal fee for MD residents is $5). Discount Medical Plan Organization and administrator: Careington International Corporation, 7400 Gaylord Parkway, Frisco, TX 75034; phone (800) 441-0380.

Note to Texas Consumers: Regulated by the Texas Department of Licensing and Regulation, P.O. Box 12157, Austin, Texas 78711; telephone (800) 803-9202 or (512) 463-6599 website: www.license.state.tx.us/complaints. The program and its administrators have no liability for providing or guaranteeing service by providers or the quality of service rendered by providers. *Medicare statement applies to MD residents when pharmacy discounts are part of program. This program is not available in Montana and Vermont.