Common Injuries Benefit Low Plan Benefit High Plan Burns (2 nd degree, at least 36% of body) $1,125 $1,500 Burns (3 rd degree, at least 2% but less than 4% of the total body surface area) $6,000 $8,500 Burns (3 rd degree, 4% or more of the total body surface area) $12,500 $20,000 Skin Grafts (percentage of burn benefit) 50% 50% Emergency Dental Work (Crown) $300 $450 Emergency Dental Work (Extraction) $100 $150 Eye Injury (removal of foreign object) $200 $300 Eye Injury (surgery) $275 $400 Torn Hip, Knee or Shoulder Cartilage (surgery with no repair or if cartilage is shaved) $250 $500 Torn Hip, Knee or Shoulder Cartilage (surgical repair) $1,000 $2,000 Laceration 1 (treated - no sutures) $25 $50 Laceration 1 (sutures up to 2) $50 $90 Laceration 1 (sutures 2 to 6) $200 $350 Laceration 1 (sutures over 6) $400 $750 Puncture Wound 1 $25 $50 Ruptured Disk (surgical repair) $1,000 $1,500 Tendon, Ligament, Rotator Cuff (exploratory arthroscopic surgery with no repair) $350 $600 Tendon, Ligament, Rotator Cuff (1, surgical repair) $675 $925 Tendon, Ligament, Rotator Cuff (2 or more, surgical repair) $1,000 $1,500 Concussion $200 $350 Traumatic Brain Injury $1,500 $2,000 Paralysis (monoplegia) $7,500 $12,500 Paralysis (hemiplegia) $12,500 $17,500 Paralysis (paraplegia) $15,000 $25,000 Paralysis (quadriplegia) $30,000 $50,000 Dislocations Complete 2 /Complete Requiring Surgical Repair 3 Benefit Low Plan Benefit High Plan Hip Joint $2,550/$5,100 $4,000/$8,000 Knee $1,600/$3,200 $2,500/$5,000 Ankle or foot bone(s) (other than toes) $1,300/$2,600 $1,500/$3,000 Shoulder $1,000/$2,000 $1,600/$3,200 Elbow $750/$1,500 $1,100/$2,200 Wrist $750/$1,500 $1,100/$2,200 Finger/toe $175/$350 $275/$550 Hand bone(s) (other than fingers) $750/$1,500 $1,100/$2,200 Lower jaw $750/$1,500 $1,100/$2,200 Collarbone $750/$1,500 $1,100/$2,200 Incomplete dislocations: percentage of the complete amount 25% 25%