T.D.B. vs. 1118 ENG Covers expenses related to thedentalprocedures listed below provided by CignaDentalTable dentists withtheinsured beingliableto pay theamountsstipulated herein. CIGNA DENTAL 2019 TABLE OFFEES DENTAL AESTHETICS * Doesnotincludethecleaningofremovable prosthesis orimplants 1.- PREVENTIVEANDCOSMETIC IMPLANT STUDY &MAINTENANCE AESTHETIC SMILEDESIGN COMPLEMENTARY EXAMINATIONS RADIOGRAPHS 0.- ORALDIAGNOSIS 0750 0220 0720 0460 0450 0440 0700 0430 0420 0250 0224 0550 0530 0520 0222 0140 0410 0190 0150 0130 0310 0120 0210 0710 1540 0415 0214 1560 1550 1530 1520 ZONA B 0312 0510 0212 1535 0110 1410 1140 1510 1150 1310 1130 1210 1120 1515 1110 1115 1117 1111 Lumineers®daVinci® ultra-slim (notcarved) E. max®pressed porcelain veneer Aesthetic lithiumdisilicate veneer Porcelain veneer Composite veneer Whitening ofnonvitaltooth (persession) Plasma orlaserlightwhitening (perarch) Mock up/ModelAesthetic test (perpiece) Biomodel Blood collection for distinct profiles Microbiological test /biochemicalstudies (sampling) Biopsy (sampling) Cephalometrics Diagnostic photography Planning 3Dmodelswithoutsurgical splints(scanner notincluded) polishing ofprostheses, radiographs andretraining onoral hygiene Full annualmaintenance: bougienage, prophylaxis, disassembly and Only at authorized network clinics(Tel. 902 040344) Nocturnal, weekend andholiday emergencies. Checkup Professional assessment Emergency examination (during consultation hours) Quote Initial oral examination anddiagnosis Whitening ofvitalteeth (perarch) Tooth polishing(fluoridepaste) Second Periodontal Scalingandsuccessive (oral cleaning)* Prophylaxis (annualteeth cleaning) or videos) Study and planningfor digitalrecreation (includesphotographs and/ Use ofbicarbonate (difficult stains) Data intake withintraoral scanner Desensitising sealing(hypersensitivity treatment) Sealing ofpitsandfissures (permanentmolars) Topical application offluoride, persession (twice a year) Staining andplaqueindex Diet planfor decay control Training onOral brushingtechnique Training onOral hygiene Orthopantomography Bitewing X-Rays Occlusal X-Rays Periapical X-Rays Basic periodicmaintenance photography andradiological-surgical splint Clinical examination, orthopantomography withmarkers, models, Waxing diagnosis(pertooth) Study models CT scan/Dentascan(bothjaws) X-Rays ofthetempomandibular joint Lateral X-Rays (Teleradiography) CT scan/Dentascan(one jaw orsector) X-RaysPeriodontal Aragón, Cataluña, IslasBaleares, LaRioja,Madrid,Navarra yPaís Vasco Customer Service 91418 40-93 301 06 56|www.cigna.es € 390 € 350 € 320 € 320 € 370 € € 180 € 180 € 130 € 130 € 216 € 216 € 155 € 155 € 125 € 125 € 40 € 90 € 44 € 44 € 80 € 80 € 50 € 50 € 50 € 30 € 30 € 20 € 20 € 65 € 65 € 95 95 € € 38 € 38 € 32 € 32 € 10 € 10 € 31 € 31 € 21 € 21 € 21 free free free free free free free free free free free free free free free free free free free free free free free INLAYS 2.- PERIORAL AESTHETICS PULPECTOMY: (including3500 andnecessary X-rays) 3.- SPACE MAINTAINERS PEDIATRIC 2450 2440 2450 2430 2430 2240 2420 2420 3306 2434 2434 3305 2550 2205 2520 2436 2230 2436 2220 2432 2432 2225 1640 2410 2410 2140 1630 2160 2190 1620 2414 2150 2105 2510 2310 2130 2210 2120 2145 2412 2412 2147 1635 2165 1625 2155 2152 1610 2110

Gingival surgery (pertooth) Extraction, deciduoustooth incisionanddrainagePulp (emergency treatment) Recement inlay Composite inlay Porcelain inlay Noble metalinlay CAD/CAM inlay Direct pulpcapping Major restoration withfiberorcarbonpost uglyirregularities (incisorremodelling, etc.) Direct preprosthetic post impression Fitting ofintraradicular post orcast post andcore Fitting pins Extra for laserdecay treatment Amalgam polishing Indirect pulpcapping Root-end barrierformation (per visit) Pulpotomy Hyaluronic acidfilling for nasolabialfurrows (persession) Hyaluronic acidfilling for lips(pervial) Hyaluronic acidfilling for marionette lines(persession) Hyaluronic acidfilling for nasogenianfurrows (persession) Facial mesotherapy (persession) Supplement for mechanized root canals withrotary instruments Metal inlay (per session) Hyaluronic acidfilling for nasogenianfurrows +marionette lines+lip Supplement for root canals performed under microscope Indirect pulpcapping Stainless steel preformed crown Restoration Amalgam (filling) Pulpotomy Gingival surgery (pertooth) incisionanddrainagePulp (emergency treatment) Root-end barrierformation (pervisit) Amalgam (filling) Restoration Sealing ofpitsandfissures (permanentmolars) Major restoration withdowels and/or pins(cores) Complex amalgam(reconstruction) Amalgam (2surfaces) Amalgam (1surface) Provisional obturation /Filling Removable, acrylic Fixed, unilateral type Recementing Stainless steel preformed crown Temporary fillingindeciduous teeth (children upto age14included)Permanent dentition (children upto age14included) Deciduousdentition € 280 € 280 € 280 € 320 € 370 € € 245 € 245 € 120 € 130 € 130 € 145 € 145 € 20 € 20 € 20 € 20 € 30 € 30 € 66 € 66 € 48 € 48 € 98 € 98 € 68 € 68 € 26 € 26 € 39 39 € 39 € € 58 € 58 € 58 € 58 € 28 € 28 € 25 € 38 € 38 € 22 € 22 € 31 € 31 free free free free free free free free free free free free free free free free free free free free free free f ree T.D.B. vs. 1118 ENG FIXED PROTHESIS 5.- REGENERATIVE THERAPY -BONEGRAFTING 4.- PERIODONTICS ENDODONTRIC SURGERY 3440 4290 4850 4550 4450 4820 4350 4430 4520 4330 4035 4420 4320 3420 4740 4230 5050 5040 4220 3500 4590 5030 4030 4770 5020 4020 3350 5025 3330 3320 4825 4010 4410 3335 3325 5010 4810 4510 5140 4310 3410 4130 4210 4120 4710 5190 5160 5180 5150 5210 5130 3310 5120 5170 5145 5185 3315 4110 5110 Periodontal splintingperpiece Free mucosal orconnective graft Laser treatment (persession) Peridontogram Periodontal splinting(sector) Apex-formation withMTA (2sessions) Maryland Bridge Zirconium crown orbridge(CAD/CAM) Noble metal/titanium crown orbridge Metal/porcelain crown orbridge Flap surgery withgraft (perquadrant) Flap surgery withgraft (persextant) Flap surgery withgraft (perpiece) Periodontal flapsurgery (perquadrant) Periodontal flapsurgery (persextant) Modified Widman flap procedure (perquadrant) Autologous bonegraft (chin, tuberosity...) Retention pinorscrew (each) Jaw remodelling withbonefilling Retreatment 2canals(X-rays included) Retreatment 1canal(X-rays included) Retreatment 3canals(X-rays included) Metal/resin crown orbridge Metal crown orbridge Partial crown Pulp incisionanddrainagePulp (Emergency treatment) Root amputation (hemisection) Retro filling(for root) Periodontal surgery (surgical curettage perpiece) Clinical crown extension (hard tissue) Alveoloplasty orbonefilling(biomaterials) Plasma richingrowth factors (P.R.G.F.) Titanium mesh Special modelcasting Dentoalveolar impression andmodelpositives Exploración yevaluación para rehabilitación protésica Regenerative Membrane Temporary Resin Crown Relining orprovisional conditioner, removable dentures Occlusal Adjustments to fitted prostheses Obtaining intermaxillary records Root canal(3 ormore canals) (X-rays included) Root canal(2 canals) (X-rays included) Root canal(1 canal) (X-rays included) Procera Allceram jacket orLithiumdisilicate Condensed porcelain jacket (In-Ceram type) Cast orinjected porcelain jacket (Empress type) Acrylic orComposite Jacket Occlusal examination Local chemotherapy application Periodontal evaluation (sounding) Periapical surgery () Scaling androot planing(perquadrant) Occlusal adjustment by balancing/selective grinding Gingivectomy orgingivoplasty (perquadrant) Gingivectomy orgingivoplasty (persextant) Gingivectomy orgingivoplasty (pertooth) glycerin Decontamination ofperiodontalpockets and/orperiimplantitisusing Periodontal treatment maintenance (throughout themouth) Customer Service 91418 40-93 301 06 56|www.cigna.es € 200 € 200 € 290 € 290 € 209 € 209 € 390 € 390 € 390 € 390 € 330 € 330 € 230 € 230 € 342 € 342 € 224 € 224 € 226 € 226 € 795 795 € € 120 € 120 € 310 € 310 € 102 € 102 € 170 € 166 € 166 € 107 € 124 € 124 € 165 € 165 € 147 € 132 € 132 € 127 € 127 € 173 € 116 € 116 € 121 € 121 € 112 € 112 € 112 € 112 € 40 € 40 € 60 € 60 € 46 € 46 € 70 70 € € 66 € 66 € 48 € 48 € 45 € 45 € 43 € 43 € 89 89 € € 89 89 € € 67 67 € € 55 € 55 € 25 € 25 € 28 € 28 € 25 € 28 € 32 € 32 € 22 € 22 € 77 € 77 € 87 87 € € 16 € 16 € 21 € 21 free free free free free free free free free free COMPOSITE PROSTHESES REMOVABLE PROSTHESIS 6.- OCCLUSION /TMJ REPAIR PROCEDURES IMPLANT PROSTHETICS 5840 5540 5860 5420 5740 5950 5630 5560 5930 5920 5850 5830 5820 5520 5546 5634 5330 5570 5230 5924 5730 5720 5940 5854 5636 5865 5542 5955 5565 5529 5858 5632 5922 5853 5852 5528 5335 5525 5522 6140 5410 5910 6130 6120 5810 5510 5310 6134 5710 5415 5816 6135 6132 5815 5817 5715 6110 Hybrid prosthesis screwed onto implants(porcelain teeth) Hybrid prosthesis screwed onto implants(resin teeth) Mucosa-implant supported overdenture (withriders) Two barson4ormore implants Bar on3ormore implants Bar on2implants Ball attachment (0-Ring,Dal-Ro, amongothers) Dental crown orbridgeunitinzirconia (CAD/CAM) Noble metal/titaniumcrown orbridge retainers /hooks…) Skeletal partialdentures (10ormore teeth) (itincludesbraces, plates, Zirconium abutment LOCATOR® typeanchor Temporary crown onIPIs retainers /hooks…) Skeletal partialdentures (4to 6teeth) (itincludesbraces, plates, retainers /hooks…) Skeletal partialdentures (1to 3teeth) (itincludesbraces, plates, retainers /hooks…) Skeletal partialdentures (7to 9teeth) (itincludesbraces, plates, Angle orcosmetic abutment Soft resin rebase Common rebase Temporary tissue adaptation (old prosthetic) Rebasing specialmaterials Tooth retention system replacement (teflon, retainer…) Aesthetic clasp Checkup, adjustment orgrindingofsplint Soft relaxation plate orwhitening tray Semi-rigid splintormouthguard Hard discharge splint(Michigan kind) Periodontal splinting Prosthesis Restoration oradditionofdentalpieces offlexible Removable Partial Neobase to rebase more than5dentalpieces Porcelain fixture Mechanical bridgedismantling Recement crowns Cast noblemetal stump Supplement for hypoallergenic orappropriate resin Partial acrylic (7ormore teeth) Transepithelial abutment Partial flexible (Valplast orFlexite...) (1 to 3 teeth) Supplement for porcelain teeth (pertooth) Partial acrylic (4to 6teeth) Partial acrylic (1to 3teeth) Complete acrylic(upperorlower) Occlusal analysis andmountinginarticulator Replace pieces orretainer orsupport Simple resin repair Parcial flexible (Valplast orFlexite...) (4 to 6 teeth) Selective grinding Neobase to rebase upto 5dentalpieces Parcial flexible (Valplast orFlexite...) (7ormore teeth) Cast metalstump, more thanoneroot Cast metalstump, oneroot Bridge supportoronlay Telescopic crown Complex precision attachment Simple precision attachment Retention magnets Retention bar € 2,060 € 1,850 € 1,850 € 600 € 600 € 500 € 500 € 200 € 200 € 300 € 300 € 700 € 450 € 450 € 420 € 420 € 390 € 390 € 580 € 580 € 470 470 € € 220 € 220 € 380 € 380 € 330 € 330 € 320 € 320 € 370 370 € € 100 € 100 € 238 € 238 € 140 € 140 € 140 € 140 € 190 € 190 € 190 € 190 € 180 € 180 € 150 € 150 € 150 € 150 € 170 € 415 € 155 € 155 € 188 € 188 € 138 € 138 € 110 € 110 € 115 € 115 € 40 € 40 € 40 € 40 € 90 € 90 € 90 € 90 € 44 € 44 € 80 € 80 € 80 € 80 € 20 € 20 € 20 € 64 € 64 € 70 70 € € 70 70 € € 45 € 45 € 54 € 54 € 42 € 42 € 86 € 86 € 95 95 € € 58 € 58 € 38 € 38 € 23 € 23 € 52 52 € € 75 75 € € 57 57 € € 14 € 14 T.D.B. vs. 1118 ENG 9.- 8.- IMPLANTOLOGY 7.- ORALSURGERY 6600 8340 8390 7430 7340 7420 8290 8260 7900 7890 7860 8200 8400 7590 7360 8350 8280 6200 8330 8250 8320 7850 7350 7330 7250 7320 7730 7220 7720 7865 8282 7855 7852 8100 8010 7410 8106 6510 9210 8105 8310 8103 8210 7810 7310 7210 7120 9215 9212 8281 7125 8101 8110 7110 9119 9118 9115 8111 Treatment withfixed multi-bracket apparatus Orthodontic study Surgical extraction of implant Peri-implant surgery Autologous bonegraft (chin, tuberosity, etc.) Bone filling(biomaterials) Membrana reabsorvible Maxillary sinuselevation (only surgery) Osseointegrated endosseous implant Surgical splintfor guidedsurgery (6ormore implants) Pre-implant surgery Fenestration to uncover implant Implant replica Healing post Closure screw /cap Microimplant for orthodontictraction Immediate provisional implants(IPIs) Special implants(wideplatform, immediate loading...) - withmetalbrackets (down payment for onesetofteeth) Positioning splint Diagnostic orradiological prosthesis for 2ormore implants Splints pilotdrillguide(4ormore implants) Splints pilotdrillguide(guidance marker) Surgical splintfor guidedsurgery (withtitaniumcylinders) - withmetalbrackets (down payment for bothsetsof teeth) Complicated suture or>5cm.(non-dentaltreatment) Stitch removal Recent wound suture <5cm.(non-dentaltreatment) Laser treatment (persession) Conditioning of removable prosthetic tissues Ostectomry (removal ofexostosis, torus, etc.) Preprosthetic surgery Sedation withnitrous oxide Sialolithotomy Removal ofsubmucosal foreign body Postoperative monitoring Crown exposure for orthodontictraction Tooth extraction andreimplantation Re-implant, stabilisation oftooth subluxation oravulsion TemporoMandibular JointPhysiotherapy (per session) Diagnostic orradiological splints Dental implantexamination Only includingtreatment plan Includes cephalometry, photos andtreatment plan Online Conductive alveolotomy (unerupted tooth exposure) osteotomy) Extraction, impacted tooth inbonetissue (withtooth divisionand/or Wisdom tooth surgical extraction semiincluded Complex root extraction Complicated extraction and/orsuture Simple tooth extraction Incision anddrainage ofperiodontalabscesses Surgical crown lengthening Minor surgery (soft tissue, epuli,fibroma...) Oroantral fistula orsinusperforation Cystectomy withorwithouttooth extraction Frenectomy apnea (SAHOS) Intraoral anti-snoringappliances (roncopathy) /obstructive sleep IMuscle orTMJjointinfiltration monthly fee* Customer Service 91418 40-93 301 06 56|www.cigna.es

€ 600 € 600 € 500 € 500 € 500 € 500 € 420 € 420 € 209 € 209 € 550 € 550 € 250 € 250 € 205 € 205 € 350 € 350 € 795 795 € € 725 € 725 € 150 € 150 € 130 € 130 € 130 € 130 € 166 € 166 € 124 € 124 € 115 € 115 € 50 € 50 € 50 € 50 € 50 € 50 € 30 € 30 € 20 € 20 € 62 € 62 € 93 93 € € 93 93 € € 82 € 82 € 22 € 75 75 € € 61 61 € free free free free free free free free free free free free free free free free free free free free free free free free free free free free free be carriedout(revisions are cost free). * Monthlyfees are deferred payments for treatment andtherefore, notrelated to thenumberofrevisions to 9340 9402 9420 9400 9240 9500 9505 9520 9330 9720 9370 9320 9250 9230 9294 9220 9345 9296 9245 9242 9298 9295 9293 9292 9297 9335 9725 9325 9375 9332 9235 9228 9372 9322 9225 9232 9222 9410 9510 9710 9310 9291 9715 9315 9312 Orthopedic forces +removable appliance (e.g.: chincup+plate) Orthopedic forces +fixed appliance (e.g.: disjunction+ face mask) Mixed treatments: Interceptive and/or orthopedictreatments Orthodontics withinvisible braces INVISALIGN® Orthodontics for orthognathic surgery (down payment) was performed by anotherclinic) Disassembly ofappliance andteeth polishing(only ifthetreatment Appliance repair Preparation for surgical splint:monomaxillar Replacement ofbracket (from 3rd loss) each Replacement oflost appliance Post-treatment stability (initialretainer for onesetofteeth) monitoring ofretainer Aesthetic retaining Post-treatment stability (initialretainer for bothsetsofteeth) - down payment for onesetofteeth both setsofteeth - (asthesoleappliance for thewhole treatment) down payment for With fixed appliance (eg.: Q-H,B.P., NANCE,etc.) - down payment for bothsetsofteeth Short-term preprosthetics (down payment) one setofteeth - (asthesoleappliance for thewhole treatment) down payment for - eachpositionerplusupto 3 - entrypositioner2arches Ortho Tain®-type preformed positioners - withremovable plates (for onesetofteeth) - withremovable plates (for bothsetsofteeth) Loss ofaligner(each) Mid-treatment correction Further adjustments (first isincludedintreatment) Teen® Lite® (upto 14aligners) Express® (upto 7aligners) Comprehensive® (from 14alignerscombined withapt.fix) Comprehensive® (from 14aligners) Additional appliances set ofteeth) - Self-ligating system (DAMON, etc.) (down payment for one sets ofteeth) - Self-ligating system (DAMON, etc.) (down payment for both - LINGUAL technique (down payment for onesetofteeth) - LINGUAL technique (down payment for bothsetsofteeth) Treatment supplementfor sapphire brackets (perarch) - withaesthetic brackets (down payment for onesetofteeth) - withaesthetic brackets (down payment for bothsetsofteeth)

monthly payment (inbothcases)* monthly (18months)* monthly fee* bimaxillar monthly fee* monthly fee* monthly fee* monthly fee* monthly fee* monthly fee*

€ 4,000 € 4,000 € 4,500 € 4,500 € 3,500 € 3,500 €2,000 € 1,050 € 1.290 € 1.290 € 900 € 900 € 900 € 900 € 200 € 200 € 450 € 450 € 450 € 450 € 690 € 260 € 260 € 550 € 550 € 250 € 250 € 350 € 350 € 250 € 250 € 350 € 350 € 385 € 385 € 285 € 285 € 735 735 € € 375 375 € € 160 € 160 € 190 € 190 € 410 € 190 € 190 € 710 € 710 € 150 € 150 € 150 € 150 € 315 € 315 € 135 € 135 € 40 € 40 € 40 € 40 € 50 € 50 € 50 € 50 € 30 € 30 € 30 € 30 € 30 € 30 € 30 € 30 € 30 € 30 € 30 € 32 € 32 € 25 € 25 € 10 € 10