RL-ACC3-CERT2-23-IN 4 D12967 (11/25) ACCIDENT BENEFITS ACCIDENT HOSPITAL CARE Low Plan High Plan Surgery - open abdominal, thoracic $1,000 $2,500 Surgery - exploratory or without repair $150 $400 Blood, Plasma, Platelets $400 $650 Hospital Admission $1,000 $2,000 Hospital Confinement $225 $400 Critical Care Unit (CCU) Admission $1,000 $2,000 Critical Care Unit (CCU) Confinement $350 $600 Rehabilitation Facility Confinement $150 $250 Non-Induced Coma $11,500 $20,000 Induced Coma $100 $250 Transportation $500 $850 Lodging $150 $225 Family Care $20 $40 ACCIDENT CARE Low Plan High Plan Initial Doctor Visit $60 $150 Urgent Care Facility Treatment $150 $300 Emergency Room Treatment $150 $350 Ambulance Ground $250 $600 Air $1,000 $2,500 Follow-Up Doctor Treatment $60 $150 Chiropractic Treatment $30 $75 Medical Equipment $400 $600 Physical or Occupational Therapy $50 $75 Speech Therapy $50 $75