Page 12 Benefit plan and Features - High Plan Lacerations Employee Spouse Child Laceration(s) with no sutures and treated by a physician $100 $100 $100 Single laceration under 5 cm with sutures $150 $150 $150 Lacerations 5–15 cm with sutures (total of all lacerations) $500 $500 $500 Lacerations greater than 15 cm with sutures (total of all lacerations) $1,000 $1,000 $1,000 Surgery Employee Spouse Child Miscellaneous surgery requiring general anesthesia not otherwise listed (once per 24- hour period, even though multiple surgical procedures may be performed) $1,000 $1,000 $1,000 Open surgery $3,000 $3,000 $3,000 Exploratory surgery or debridement $800 $800 $800 Laparoscopic surgery or hernia repair $1,000 $1,000 $1,000 Tendon/Ligament/Rotator cuff tear $1,500 $1,500 $1,500 Torn knee cartilage $1,500 $1,500 $1,500 Ruptured/herniated disc $1,500 $1,500 $1,500 Burns Employee Spouse Child 21–40 sq. cm second degree $400 $400 $400 21–40 sq. cm third degree $1,000 $1,000 $1,000 41–65 sq. cm second degree $800 $800 $800 41–65 sq. cm third degree $2,000 $2,000 $2,000 66–160 sq. cm second degree $1,200 $1,200 $1,200 66–160 sq. cm third degree $6,000 $6,000 $6,000 161–225 sq. cm second degree $1,600 $1,600 $1,600 161–225 sq. cm third degree $14,000 $14,000 $14,000 More than 225 sq. cm second degree $2,000 $2,000 $2,000 More than 225 sq. cm third degree $20,000 $20,000 $20,000 Skin graft 50% of the applicable burn benefit Medical services Employee Spouse Child Diagnostic exam (one-time per benefit year): Arteriogram, angiogram, CT, CAT, EKG, EEG or MRI $300 $300 $300 X-ray (twice per covered accident) $100 $100 $100 Accident emergency treatment (non-ER or non-urgent care facility) (one time per covered accident) $100 $100 $100