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B1I09CIGNA DENTAL CARE (*DHMO)PATIENT CHARGE SCHEDULEThis Patient Charge Schedule lists the benefits of the Dental Plan includingcovered procedures and patient charges.Important Highlights This Patient Charge Schedule applies only when covered dental services areperformed by your Network Dentist, unless otherwise authorized by Cigna Dentalas described in your plan documents. Not all Network Dentists perform all listedservices and it is suggested to check with your Network Dentist in advance ofreceiving services. This Patient Charge Schedule applies to Specialty Care when an appropriate referralis made to a Network Specialty Periodontist or Oral Surgeon. You must verify withthe Network Specialty Dentist that your treatment plan has been authorized forpayment by Cigna Dental. Prior authorization is not required for specialty referralsfor Pediatric, Orthodontic and Endodontic services. You may select a NetworkPediatric Dentist for your child under the age of 7 by calling Customer Service at1.800.Cigna24 to get a list of Network Pediatric Dentists in your area. Coveragefor treatment by a Pediatric Dentist ends on your child’s 7th birthday; however,exceptions for medical reasons may be considered on an individual basis. YourNetwork General Dentist will provide care upon your child’s 7th birthday. Procedures not listed on this Patient Charge Schedule are not covered and arethe patient’s responsibility at the dentist’s usual fees. The administration of IV sedation, general anesthesia, and/or nitrous oxide isnot covered except as specifically listed on this Patient Charge Schedule. Theapplication of local anesthetic is covered as part of your dental treatment. Cigna Dental considers infection control and/or sterilization to be incidental toand part of the charges for services provided and not separately chargeable.92249909351 08/17 B1I09

CIGNA DENTAL CARE PATIENT CHARGE SCHEDULE (B1I09)Important Highlights (continued) This Patient Charge Schedule is subject to annual change in accordance with theterms of the group agreement. Procedures listed on the Patient Charge Schedule are subject to the planlimitations and exclusions described in your plan book/certificate of coverageand/or group contract. All patient charges must correspond to the Patient Charge Schedule in effect onthe date the procedure is initiated. The American Dental Association may periodically change CDT Codes ordefinitions. Different codes may be used to describe these covered procedures.CodePatientChargeProcedure DescriptionDiagnostic/preventive – Oral evaluations are limited to a combined total of 4of the following evaluations during a 12 consecutive month period: Periodic oralevaluations (D0120), comprehensive oral evaluations (D0150), comprehensiveperiodontal evaluations (D0180), and oral evaluations for patients under 3 yearsof age (D0145).D9310Consultation (diagnostic service provided by dentist orphysician other than requesting dentist or physician) 0.00D9430Office visit for observation – No other services performed 0.00D9450Case presentation – Detailed and extensivetreatment planning 0.00D0120Periodic oral evaluation – Established patient 0.00D0140Limited oral evaluation – Problem focused 0.00D0145Oral evaluation for a patient under 3 years of age andcounseling with primary caregiver 0.00D0150Comprehensive oral evaluation – New or established patient 0.00D0160Detailed and extensive oral evaluation – problem focused,by report (limit 2 per calendar year; only covered in conjunctionwith Temporomandibular Joint (TMJ) evaluation) 0.00D0170Reevaluation – Limited, problem focused (notpostoperative visit) 0.00-2-

CIGNA DENTAL CARE PATIENT CHARGE SCHEDULE (B1I09)PatientChargeCodeProcedure DescriptionD0180Comprehensive periodontal evaluation – New orestablished patientD0210X-rays intraoral – Complete series of radiographic images(limit 1 every 3 years) 0.00D0220X-rays intraoral – Periapical – First radiographic image 0.00D0230X-rays intraoral – Periapical – Each additionalradiographic image 0.00D0240X-rays intraoral – Occlusal radiographic image 0.00D0270X-rays (bitewing) – Single radiographic image 0.00D0272X-rays (bitewings) – 2 radiographic images 0.00D0273X-rays (bitewings) – 3 radiographic images 0.00D0274X-rays (bitewings) – 4 radiographic images 0.00D0277X-rays (bitewings, vertical) – 7 to 8 radiographic images 0.00D0330X-rays (panoramic radiographic image) – (limit 1 every3 years) 0.00D0364Cone beam CT capture and interpretation with limited fieldof view – less than one whole jaw (only covered in conjunctionwith the surgical placement of an implant; limit of a total ofonly one D0364, D0365, D0366 or D0367 per calendar year) 200.00D0365Cone beam CT capture and interpretation with field ofview of one full dental arch – mandible (only covered inconjunction with the surgical placement of an implant; limitof a total of only one D0364, D0365, D0366 or D0367 percalendar year) 220.00D0366Cone beam CT capture and interpretation with field of viewof one full dental arch – maxilla, with or without cranium(only covered in conjunction with the surgical placement of animplant; limit of a total of only one D0364, D0365, D0366 orD0367 per calendar year) 220.00D0367Cone beam CT capture and interpretation with field ofview of both jaws, with or without cranium (only coveredin conjunction with the surgical placement of an implant;limit of a total of only one D0364, D0365, D0366 or D0367per calendar year) 240.00-3- 18.00

CIGNA DENTAL CARE PATIENT CHARGE SCHEDULE (B1I09)PatientChargeCodeProcedure DescriptionD0368Cone beam CT capture and interpretation for TMJ seriesincluding two or more exposures (limit 1 per calendar year;only covered in conjunction with Temporomandibular Joint(TMJ) evaluation)D0431Oral cancer screening using a special light source 50.00D0460Pulp vitality tests 14.00D0470Diagnostic casts 0.00D0472Pathology report – Gross examination of lesion (only whentooth related) 0.00D0473Pathology report – Microscopic examination of lesion(only when tooth related) 0.00D0474Pathology report – Microscopic examination of lesion andarea (only when tooth related) 0.00D1110Prophylaxis (cleaning) – Adult (limit 2 per calendar year) 0.00Additional prophylaxis (cleaning) – In addition to the2 prophylaxes (cleanings) allowed per calendar yearD1120Prophylaxis (cleaning) – Child (limit 2 per calendar year)Additional prophylaxis (cleaning) – In addition to the2 prophylaxes (cleanings) allowed per calendar yearD1206D1208Topical application of fluoride varnish (limit 2 per calendaryear). There is a combined limit of a total of 2 D1206s and/orD1208s per calendar year. 240.00 45.00 0.00 30.00 0.00Additional topical application of fluoride varnish – In additionto any combination of two (2) D1206s (topical applicationof fluoride varnish) and/or D1208s (topical application offluoride) per calendar year. 15.00Topical application of fluoride (limit 2 per calendar year).There is a combined limit of a total of 2 D1208s and/or D1206sper calendar year. 0.00Additional topical application of fluoride – In addition toany combination of two (2) D1206s (topical applicationsof fluoride varnish) and/or D1208s (topical application offluoride) per calendar year.-4- 15.00

CIGNA DENTAL CARE PATIENT CHARGE SCHEDULE (B1I09)PatientChargeCodeProcedure DescriptionD1330Oral hygiene instructions 0.00D1351Sealant – Per tooth 0.00D1352Preventive resin restoration in a moderate to high cariesrisk patient – Permanent tooth 0.00D1510Space maintainer – Fixed – Unilateral 0.00D1515Space maintainer – Fixed – Bilateral 0.00D1555Removal of fixed space maintainer 0.00Restorative (fillings, including polishing)D2140Amalgam – 1 surface, primary or permanent 0.00D2150Amalgam – 2 surfaces, primary or permanent 0.00D2160Amalgam – 3 surfaces, primary or permanent 0.00D2161Amalgam – 4 or more surfaces, primary or permanent 0.00D2330Resin-based composite – 1 surface, anterior 0.00D2331Resin-based composite – 2 surfaces, anterior 0.00D2332Resin-based composite – 3 surfaces, anterior 0.00D2335Resin-based composite – 4 or more surfaces or involvingincisal angle, anterior 88.00D2390Resin-based composite crown, anterior 37.00D2391Resin-based composite – 1 surface, posterior 47.00D2392Resin-based composite – 2 surfaces, posterior 59.00D2393Resin-based composite – 3 surfaces, posterior 82.00D2394Resin-based composite – 4 or more surfaces, posterior-5- 115.00

CIGNA DENTAL CARE PATIENT CHARGE SCHEDULE (B1I09)CodePatientChargeProcedure DescriptionCrown and bridge – All charges for crown and bridge (fixed partial denture)are per unit (each replacement or supporting tooth equals 1 unit). Coverage forreplacement of crowns and bridges is limited to 1 every 5 years.Per tooth charge for crowns, inlays, onlays, post and cores,and veneers if your dentist uses same day in-office CAD/CAM(ceramic) services. Same day in-office CAD/CAM (ceramic)services refer to dental restorations that are created inthe dental office by the use of a digital impression and anin-office CAD/CAM milling machine. 150.00D2510Inlay – Metallic – 1 surface 245.00D2520Inlay – Metallic – 2 surfaces 245.00D2530Inlay – Metallic – 3 or more surfaces 245.00D2542Onlay – Metallic – 2 surfaces 215.00D2543Onlay – Metallic – 3 surfaces 215.00D2544Onlay – Metallic – 4 or more surfaces 215.00D2740Crown – Porcelain/ceramic substrate 240.00D2750Crown – Porcelain fused to high noble metal 230.00D2751Crown – Porcelain fused to predominantly base metal 185.00D2752Crown – Porcelain fused to noble metal 220.00D2780Crown – 3/4 cast high noble metal 235.00D2781Crown – 3/4 cast predominantly base metal 190.00D2782Crown – 3/4 cast noble metal 225.00D2790Crown – Full cast high noble metal 235.00D2791Crown – Full cast predominantly base metal 190.00D2792Crown – Full cast noble metal 225.00D2794Crown – Titanium 235.00D2910Recement inlay – Onlay or partial coverage restoration 12.00D2915Recement cast or prefabricated post and core 12.00D2920Recement crown 12.00-6-

CIGNA DENTAL CARE PATIENT CHARGE SCHEDULE (B1I09)PatientChargeCodeProcedure DescriptionD2929Prefabricated porcelain/ceramic crown – Primary tooth 76.00D2930Prefabricated stainless steel crown – Primary tooth 12.00D2931Prefabricated stainless steel crown – Permanent tooth 12.00D2932Prefabricated resin crown 56.00D2933Prefabricated stainless steel crown with resin window 76.00D2934Prefabricated esthetic coated stainless steel crown –Primary tooth 76.00D2940Protective Restoration 13.00D2950Core buildup – Including any pins 44.00D2951Pin retention – Per tooth – In addition to restoration 13.00D2952Post and core – In addition to crown, indirectly fabricated 71.00D2954Prefabricated post and core – In addition to crown 61.00D2960Labial veneer (resin laminate) – Chairside 110.00D6210Pontic – Cast high noble metal 230.00D6211Pontic – Cast predominantly base metal 190.00D6212Pontic – Cast noble metal 225.00D6214Pontic – Titanium 235.00D6240Pontic – Porcelain fused to high noble metal 230.00D6241Pontic – Porcelain fused to predominantly base metal 190.00D6242Pontic – Porcelain fused to noble metal 225.00D6245Pontic – Porcelain/ceramic 210.00D6602Inlay – Cast high noble metal, 2 surfaces 235.00D6603Inlay – Cast high noble metal, 3 or more surfaces 235.00D6604Inlay – Cast predominantly base metal, 2 surfaces 190.00D6605Inlay – Cast predominantly base metal, 3 or more surfaces 190.00D6606Inlay – Cast noble metal, 2 surfaces 225.00D6607Inlay – Cast noble metal, 3 or more surfaces 225.00D6610Onlay – Cast high noble metal, 2 surfaces 235.00-7-