RL-ACC3-CERT2-23-IN 5 D12967 (11/25) Prosthetic Device - one $500 $1,500 Prosthetic Device - 2 or more $800 $2,400 Prescription Medicine $10 $20 Major Diagnostic Exams CT (computerized tomography) or CAT scan (computerized axial tomography) $125 $500 MRI (magnetic resonance imaging) $125 $500 EEG (electroencephalogram) $125 $500 PET (positron emission tomography) scan $125 $500 Ultrasound $125 $500 Outpatient Surgery $150 $300 X-ray $50 $100 COMMON INJURIES Low Plan High Plan Burns 2nd degree - at least 36% of the total body surface area $1,000 $1,750 3rd degree - at least 2% but less than 4% of the total body surface area $4,500 $10,000 3rd degree - 4% or more of the total body surface area $10,000 $22,000 Skin Grafts 50% of Burn Benefit 50% of Burn Benefit Emergency Dental Work Crown $250 $480 Extraction $60 $180 Eye Injury Surgery $225 $420 Removal of foreign object $150 $300 Torn Hip, Knee or Shoulder Cartilage Surgery with no repair or if cartilage is shaved $150 $280 Surgical repair $500 $1,000 Laceration (total of all lacerations) treated, no sutures $20 $60 sutures, up to 2 inches $50 $120 sutures, 2 to 6 inches $160 $480 sutures, over 6 inches $400 $960 Puncture Wound $25 $75 Ruptured Disk - surgical repair $500 $1,000