1. BENEFIT HIGHLIGHTS Lacerations Low Plan High Plan Laceration(s) with no sutures and treated by $20 $35 Physician Single laceration under 5 centimeters with $35 $65 sutures Lacerations 5 - 15 centimeters with sutures $125 $250 (total of all lacerations) Lacerations greater than 15 centimeters with $250 $500 sutures (total of all lacerations) Burns Low Plan High Plan nd 21 - 40 square centimeters 2 degree $200 $400 21 - 40 square centimeters 3rd degree $500 $1,000 nd 41 - 65 square centimeters 2 degree $400 $800 41 - 65 square centimeters 3rd degree $1,000 $2,000 66 - 160 square centimeters 2nd degree $600 $1,200 66 - 160 square centimeters 3rd degree $3,000 $6,000 161 - 225 square centimeters 2nd degree $800 $1,600 161 - 225 square centimeters 3rd degree $7,000 $14,000 nd More than 225 square centimeters 2 degree $1,000 $2,000 rd More than 225 square centimeters 3 degree $10,000 $20,000 Skin graft 50% of the applicable Burn Benefit Medical Services Low Plan High Plan Diagnostic Exam: Arteriogram, angiogram, CT, CAT, EKG, $100 $200 EEG, or MRI (1 time per Benefit Year) X-ray (1 time per Covered Accident) $25 $30 Accident Emergency Treatment (non- $25 $50 Emergency Room) (1 time per Covered Accident) Physician's follow-up Treatment office visit $25 $25 (per visit, up to 6 times per Covered Accident Physical and occupational therapy (per visit $25 $25 up to 10 visits per Covered Accident) Medical Devices $100 $125 Epidural Pain Management (up to 2 times per $25 $50 Covered Accident) Prescription drug $15 $25 Prosthesis (one) $250 $500 Prosthesis (two) $500 $1,000 Blood, plasma or platelet transfusion $100 $200 Hospital Low Plan High Plan Hospital admission (once per Benefit Year) $500 $1,000 16-AC-C-01 Page8