Value Plan 1
Ambulance
$300 $750 $150 $175
Knee Brace
$100
Hospital Admission Emergency Room Visit
X-Ray
$50
Knee Cartilage Tear 6 Follow-Up Visits
$500 $150
Accident Insurance Rates Employee
Hospital Confinement (1 Day) Medical Resonance Imaging (MRI)
$200 Total cash benefit paid for covered services: $2,375
$19.90 $28.30 $31.50 $39.90
Employee & Spouse Employee & Child
Family
2020-98283 (04/22)
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