Company #1 Company #2 Company #3
  Bob McCloskey Ins.    
Maximum Medical      
Deductible      
Physical Therapy Ben.      
Dental Benefit      
Hospital-In Patient      

Hospital-Out Patient
 (Emergency room)

      
Surgical Benefit      

Surgical benefit today in: ZIP Code____________ for the folowing typical Surgical Procedures

      

Wound Closure
 Proc. 12036

      

Open Treatment-Nasal
 Proc. 21325

      

Open Treatment-Shoulder
 Proc. 23660

      

Repair, Tendon or Muscle
 Proc. 25260

      

Open Treatment-Hip
 Proc. 27523

      

Open Treatment-Knee
 Proc. 27556

      

Open Treatment-Tibia
 Proc. 27758

      

Open Treatment-Ankle
 Proc. 27846

      

Will plan pay if HMO declines due to non-part-icipating provider (Y/N)?

      

Will plan pay unpaid bal-ances if UCR has been paid by family insurance (Y/N)?

      
PRICE: