RL-ACC3-CERT2-23-IN 6 D12967 (11/25) Tendon/Ligament/Rotator Cuff One, surgical repair $550 $1,020 2 or more, surgical repair $800 $1,520 Exploratory Arthroscopic Surgery with no repair $275 $720 Concussion $150 $450 Traumatic Brain Injury $1,250 $2,500 Paralysis Quadriplegia $16,000 $30,000 Paraplegia $12,000 $20,000 Hemiplegia $10,000 $20,000 Monoplegia $5,000 $15,500 Low Plan High Plan Dislocations (Complete & Complete Requiring Surgical Repair) Complete / Complete Requiring Surgical Repair Complete / Complete Requiring Surgical Repair Hip Joint $2,550/$5,100 $5,000/$10,000 Knee $1,600/$3,200 $3,000/$6,000 Ankle or Foot Bone(s) other than toes $1,000/$2,000 $1,800/$3,600 Shoulder $1,000/$2,000 $2,200/$4,400 Elbow $750/$1,500 $1,500/$3,000 Wrist $750/$1,500 $1,500/$3,000 Finger/Toe $175/$350 $350/$700 Hand Bone(s) other than fingers $750/$1,500 $1,500/$3,000 Lower Jaw $750/$1,500 $1,500/$3,000 Collarbone $750/$1,500 $1,500/$3,000 Incomplete Dislocations 25% of Complete Dislocation Amount Fractures (Non-Surgical Repair Fracture & Fracture Requiring Surgical Repair) Non-Surgical Repair Fracture / Fracture Requiring Surgical Repair Non-Surgical Repair Fracture / Fracture Requiring Surgical Repair Hip $2,000/$4,000 $6,000/$12,000 Leg $1,500/$3,000 $3,000/$6,000 Ankle $1,200/$2,400 $2,500/$5,000 Kneecap $1,200/$2,400 $2,500/$5,000 Foot (excluding toes, heel) $1,200/$2,400 $2,500/$5,000 Heel $1,200/$2,400 $2,500/$5,000 Upper Arm $1,400/$2,800 $2,750/$5,500 Forearm, Hand, Wrist (except fingers) $1,200/$2,400 $2,500/$5,000 Finger, Toe $160/$320 $400/$800 Vertebral Body $2,240/$4,480 $4,200/$8,400 Vertebral Processes $960/$1,920 $2,000/$4,000 Pelvis (except Coccyx) $2,250/$4,500 $4,000/$8,000 Coccyx $300/$600 $750/$1,500 Bones of Face (except nose) $800/$1,600 $1,400/$2,800 Nose $400/$800 $750/$1,500 Upper Jaw $1,000/$2,000 $1,750/$3,500 Lower Jaw $960/$1,920 $2,000/$4,000 Collarbone $960/$1,920 $2,000/$4,000 Rib $300/$600 $600/$1,200