Benefit Schedule (Refer to your application for the Level elected.) Level 1 Level 2 Level 3 Level 4 AO22OCFL 6 Elbow $300 $450 $600 $750 Lower Jaw $300 $450 $600 $750 Bones of the Hand (excluding fingers) $300 $450 $600 $750 Shoulder (Glenohumeral) $300 $450 $600 $750 Wrist $300 $450 $600 $750 Collarbone (Acromioclavicular and Separation) $300 $450 $600 $750 One Finger or Toe $150 $225 $300 $375 With Local Anesthesia or No Anesthesia 25% of Closed Reduction amount Fracture (Open Reduction) Skull, except Bones of the Face or Nose $4,000 $6,000 $8,000 $10,000 Hip, Thigh (Femur) $4,000 $6,000 $8,000 $10,000 Vertebrae $2,400 $3,600 $4,800 $6,000 Pelvis except Coccyx $2,400 $3,600 $4,800 $6,000 Leg (Fibula or Tibia) $2,400 $3,600 $4,800 $6,000 Ankle or Wrist $800 $1,200 $1,600 $2,000 Bones of the Face or Nose (except Mandible or Maxilla) $800 $1,200 $1,600 $2,000 Upper Jaw (Maxilla) except Alveolar Process $800 $1,200 $1,600 $2,000 Lower Jaw (Mandible) except Alveolar Process $800 $1,200 $1,600 $2,000 Arm (Radius, Ulna and/or Humerus) $800 $1,200 $1,600 $2,000 Collarbone (Clavicle or Sternum) $800 $1,200 $1,600 $2,000 Shoulder Blade (Scapula) $800 $1,200 $1,600 $2,000 Kneecap (Patella) $800 $1,200 $1,600 $2,000 Hand / Foot (except fingers / toes) $800 $1,200 $1,600 $2,000 Rib $800 $1,200 $1,600 $2,000 Coccyx $600 $900 $1,200 $1,500 One Finger or Toe $300 $450 $600 $750 Fracture (Closed Reduction) Skull, except Bones of the Face or Nose $2,000 $3,000 $4,000 $5,000 Hip, Thigh (Femur) $2,000 $3,000 $4,000 $5,000 Vertebrae $1,200 $1,800 $2,400 $3,000 Pelvis except Coccyx $1,200 $1,800 $2,400 $3,000 Leg (Fibula or Tibia) $1,200 $1,800 $2,400 $3,000 Ankle or Wrist $400 $600 $800 $1,000 Bones of the Face or Nose (except Mandible or Maxilla) $400 $600 $800 $1,000 Upper Jaw (Maxilla) except Alveolar Process $400 $600 $800 $1,000 Lower Jaw (Mandible) except Alveolar Process $400 $600 $800 $1,000 Arm (Radius, Ulna and/or Humerus) $400 $600 $800 $1,000 Collarbone (Clavicle or Sternum) $400 $600 $800 $1,000 Shoulder Blade (Scapula) $400 $600 $800 $1,000 Kneecap (Patella) $400 $600 $800 $1,000 Hand / Foot (except fingers / toes) $400 $600 $800 $1,000 Rib $400 $600 $800 $1,000 Coccyx $300 $450 $600 $750 One Finger or Toe $150 $225 $300 $375 Chip Fracture 25% of Closed Reduction Amount