1. BENEFIT HIGHLIGHTS Loss of Arm—one arm Loss of a Finger or Loss of a Toe—two or $1,500 $1,500 $750 more fingers or toes Loss of a Finger or Loss of a Toe—one $750 $750 $375 finger or one toe Loss of Sight or Loss of an Eye—one eye $7,500 $7,500 $3,750 Dislocations Open Reduction Low Plan High Plan Hip $2,000 $4,000 Knee, ankle or bones of the foot $1,000 $2,000 Elbow or wrist $400 $800 Shoulder $500 $1,000 Collarbone or bones of the hand $800 $1,600 Finger(s) or toe(s) $100 $200 Lower jaw $400 $800 Dislocations Closed Reduction Low Plan High Plan Hip $1,000 $2,000 Knee $500 $1,000 Ankle or bones of the foot $500 $1,000 Elbow or wrist $200 $400 Shoulder $250 $500 Collarbone or bones of the hand $400 $800 Finger(s) or toe(s) $50 $100 Lower jaw $200 $400 Incomplete Dislocation or a Dislocation that 100% of the applicable Closed Reduction requires reduction without Anesthesia Fractures Open Reduction Low Plan High Plan Hip or thigh $2,000 $4,000 Skull-depressed $3,000 $6,000 Skull-simple $1,500 $3,000 Vertebral processes $350 $700 Bones of face $350 $700 Bones of nose $350 $700 Leg (tibia or fibula) $1,000 $2,000 Vertebrae (body of) or sternum $800 $1,600 Pelvis (excluding coccyx) $800 $1,600 Upper jaw or upper arm $375 $750 Lower jaw $325 $650 Knee cap $325 $650 Ankle $325 $650 Foot $325 $650 Collarbone $325 $650 Shoulder $325 $650 Forearm $325 $650 Hand $325 $650 16-AC-C-01 Page6