34 Covered Medical Charges List Subject to the Schedule of Benefits, the Covered Charge Limits, the Areas of Limited Coverage provisions, and any applicable Exclusions and Limitations, the following sets forth a list of medical charges as provided under the terms of the Plan. Note: Prec ertification is required by the Plan for all inpatient and many outpatient services . See the precertification requirements section earlier in this SPD and contact Cigna directly, before services are scheduled, to determine if precertification is needed for any proposed services. Facility Charges These charges are classified as Facility Charges: • Room and board charges of an Acute Care Hospital for each day of a participant’s inpatient stay. Unless other contractual limits apply, such charges shall not be mor e than: − Routine care unit: The hospital’s average semi - private room rate − Intensive care unit: Up to 300% of the hospital’s average semi - private room rate. − Special care unit (other than intensive care unit): The hospital’s average semi - private room rate. • Ch arges of an Acute Care Hospital, other than room and board charges, for medical services and supplies furnished to a participant during his or her inpatient stay • Charges of a hospital for emergency services. • Charges of an Acute Care Hospital for medical services and supplies furnished on an outpatient basis. • Charges of an Ambulatory Surgical Facility for an outpatient surgery done in the facility. • Charges of a skilled nursing facility for the confinement of a participant as an inpatient, but only if the confinement: (a) follows a stay of at least five days as an inpatient in an Acute Care Hospital; and (b) starts within seven (7) days after the participant is discharged from that hospital stay. Unless other contractual limits apply, the covered me dical charge for all services provided on each day of confinement, will not be more than 50% of the prior Acute Care Hospital average semi - private room rate. The inpatient maximum stay for a skilled nursing facility is 100 days per calendar year. • Charges for medical services and supplies furnished by a specialized facility. Unless other contractual limits apply, the covered medical charge for room and board for each day of the participant’s inpatient stay shall be no more than the average semi - private room rate. Practitioner Charges These charges are classified as Practitioner Charges: • Charges of a physician or Allied Health Professional for the following professional services: − Office visits, visits in an Acute Care Hospital, at the patient’s home, or at a ny other covered medical facility, including urgent care facilities. − Surgery, subject to the surgery guidelines shown below. − Radiation therapy, chemotherapy, and dialysis treatment. − Anesthesiology, subject to the surgery guidelines shown below. › Surgery Gui delines: (a) If two or more surgical procedures are performed at the same time, the covered medical charges will be limited to those incurred for the major procedure plus