Type of Benefit Benefit Amount Dislocations Surgical Non-Surgical Ankle $2,100 $1,050 Collarbone $2,100 $1,050 Elbow $1,050 $525 Finger $350 $175 Foot $2,100 $1,050 Hand $1,050 $525 Hip $5,600 $2,800 Knee $3,500 $1,750 Lower Jaw $1,050 $525 Shoulder $1,050 $525 Toe $350 $175 Wrist $1,050 $525 Partial Dislocation 37.5% of benefit for non-surgical dislocation Multiple Dislocations 150% of the highest benefit for any one dislocation among all dislocations sustained Emergency Treatment $225 Epidural Anesthesia Injection $200 per injection Eye Injury Removal of Foreign Object $150 Surgical Repair $300 LRS-9548-0318-IN Page 1.2