OTHER CLAIM RELATED FEE SUMMARY                                           
                     Other Claim Related Fee Description/Incurred Date/Product/Sub Group-8 Digit                     

INVOICE NUMBER:     230801581733                                           PAGE:               1 of 2            
BILL ACCOUNT NUMBER:CN02401002                                             PAID CLAIMS MONTH:  July 2023         
BILL ACCOUNT NAME:  Admiral Peary                                          CLAIMS PAID THRU:   07/28/2023        
CLIENT NUMBER:      0240                                                   BILL CYCLE:         4 of 4            
CLIENT NAME:        Admiral Peary                                          PREPARED DATE:      08/01/2023        

Other Claim Related Fee Description                                                                                Fee Amount                            
_____________________________________________________________________________________________________________________________________________________________
                                                                                                                                                            
Prepay Claims Savings Fee
  07/23
    Prepay Claims Savings Fee
      014267-03                                                                                                     $1,012.40
      014267-54                                                                                                        $81.93
      014267- Total                                                                                                 $1,094.33
      104272-02                                                                                                        $31.50
      104272- Total                                                                                                    $31.50
    Prepay Claims Savings Fee Total                                                                                 $1,125.83
  07/23 Total                                                                                                       $1,125.83
Prepay Claims Savings Fee Total                                                                                     $1,125.83
                                                                                                                                                            
Utilization Management In Pat
  06/23
    Utilization Management In Pat
      014267-07                                                                                                       $110.00
      014267- Total                                                                                                   $110.00
    Utilization Management In Pat Total                                                                               $110.00
  06/23 Total                                                                                                         $110.00
  07/23
    Utilization Management In Pat
      014267-07                                                                                                       $110.00
      014267- Total                                                                                                   $110.00
    Utilization Management In Pat Total                                                                               $110.00
  07/23 Total                                                                                                         $110.00
Utilization Management In Pat Total                                                                                   $220.00

                                                                                                                                                PAGE:2 of 2
                                                                                                                                                            
Other Claim Related Fee Description                                                                                Fee Amount                            
_____________________________________________________________________________________________________________________________________________________________
                                                                                                                                                            
Utilization Management Out Pat
  04/23
    Utilization Management Out Pat
      014267-13                                                                                                       $110.00
      014267- Total                                                                                                   $110.00
    Utilization Management Out Pat Total                                                                              $110.00
  04/23 Total                                                                                                         $110.00
  05/23
    Utilization Management Out Pat
      014267-03                                                                                                       $330.00
      014267-36                                                                                                       $220.00
      014267-54                                                                                                       $110.00
      014267- Total                                                                                                   $660.00
      104272-02                                                                                                       $550.00
      104272- Total                                                                                                   $550.00
    Utilization Management Out Pat Total                                                                            $1,210.00
  05/23 Total                                                                                                       $1,210.00
  06/23
    Utilization Management Out Pat
      014267-06                                                                                                       $110.00
      014267- Total                                                                                                   $110.00
    Utilization Management Out Pat Total                                                                              $110.00
  06/23 Total                                                                                                         $110.00
  07/23
    Utilization Management Out Pat
      104272-02                                                                                                       $110.00
      104272- Total                                                                                                   $110.00
    Utilization Management Out Pat Total                                                                              $110.00
  07/23 Total                                                                                                         $110.00
Utilization Management Out Pat Total                                                                                $1,540.00
                                                                                                                                                            
Other Claims Related Fee Summary Total                                                                              $2,885.83