1. BENEFIT HIGHLIGHTS Wrist $325 $650 Elbow $325 $650 Heel $325 $650 Rib $175 $350 Finger $175 $350 Toe $175 $350 Coccyx $175 $350 Multiple ribs $500 $1,000 Fractures Closed Reduction Low Plan High Plan Hip or thigh $1,000 $2,000 Skull-depressed $1,500 $3,000 Skull-simple $750 $1,500 Vertebral processes $175 $350 Bones of face $175 $350 Bones of nose $175 $350 Leg (tibia or fibula) $500 $1,000 Vertebrae (body of) or sternum $400 $800 Pelvis (excluding coccyx) $400 $800 Upper jaw or upper arm $190 $375 Lower jaw $170 $325 Knee cap $170 $325 Ankle $170 $325 Foot $170 $325 Collarbone $170 $325 Shoulder $170 $325 Forearm $170 $325 Hand $170 $325 Wrist $170 $325 Elbow $170 $325 Heel $170 $325 Rib $90 $175 Finger $90 $175 Toe $90 $175 Coccyx $90 $175 Multiple ribs $250 $500 Chip Fractures and other Fractures not 25% of the applicable Closed Reduction reduced by Open or Closed Reduction Additional Injuries Low Plan High Plan Eye - surgery $125 $250 Eye - object remove $125 $250 Gunshot wound $250 $500 Paralysis - paraplegia $12,500 $25,000 Paralysis - quadriplegia $25,000 $50,000 Coma $5,000 $10,000 Concussion $50 $100 16-AC-C-01 Page7