ADDITIONAL ITEMS                                                   
                Additional Item Description/Incurred Date/Product/Sub Group-8 Digit/Payroll Location                 

INVOICE NUMBER:     230117583406                                           PAGE:               1 of 1            
BILL ACCOUNT NUMBER:2401631001                                             PAID CLAIMS MONTH:  January 2023      
BILL ACCOUNT NAME:  Utz Quality Foods                                      CLAIMS PAID THRU:   01/13/2023        
CLIENT NUMBER:      240163                                                 BILL CYCLE:         2 of 4            
CLIENT NAME:        Utz Quality Foods                                      PREPARED DATE:      01/17/2023        

                                        Adjustment Description                                            Adjustment Amount                              
_____________________________________________________________________________________________________________________________________________________________
                                                                                                                                                            
Stop Loss Estimate
  01/23
    PPO
      025620-01
         PLT5                                                                                                        ($45.88)
      025620-01 Total                                                                                                ($45.88)
    PPO Total                                                                                                        ($45.88)
  01/23 Total                                                                                                        ($45.88)
Stop Loss Estimate Total                                                                                             ($45.88)
                                                                                                                                                            
Additional Items Total                                                                                               ($45.88)