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

INVOICE NUMBER:     250729587807                                           PAGE:               1 of 6            
BILL ACCOUNT NUMBER:CN02401002                                             PAID CLAIMS MONTH:  July 2025         
BILL ACCOUNT NAME:  Admiral Peary                                          CLAIMS PAID THRU:   07/25/2025        
CLIENT NUMBER:      0240                                                   BILL CYCLE:         4 of 4            
CLIENT NAME:        Admiral Peary                                          PREPARED DATE:      07/29/2025        

Other Claim Related Fee Description                                                                                Fee Amount                            
_____________________________________________________________________________________________________________________________________________________________
                                                                                                                                                            
Claims Service Program: Non-Contracted Providers
  11/24
    Claims Service Program: Non-Contracted Providers
      014267-07                                                                                                     $2,097.65
      014267- Total                                                                                                 $2,097.65
    Claims Service Program: Non-Contracted Providers Total                                                          $2,097.65
  11/24 Total                                                                                                       $2,097.65
Claims Service Program: Non-Contracted Providers Total                                                              $2,097.65
                                                                                                                                                            
Pre Pay Coding Validation
  06/25
    Pre Pay Coding Validation
      014267-36                                                                                                     ($186.02)
      014267- Total                                                                                                 ($186.02)
    Pre Pay Coding Validation Total                                                                                 ($186.02)
  06/25 Total                                                                                                       ($186.02)
  07/25
    Pre Pay Coding Validation
      014267-03                                                                                                        $25.82
      014267-15                                                                                                         $9.67
      014267- Total                                                                                                    $35.49
      104272-02                                                                                                        $31.01
      104272-19                                                                                                        $30.09
      104272- Total                                                                                                    $61.10
    Pre Pay Coding Validation Total                                                                                    $96.59
  07/25 Total                                                                                                          $96.59
Pre Pay Coding Validation Total                                                                                      ($89.43)

                                                                                                                                                PAGE:2 of 6
                                                                                                                                                            
Other Claim Related Fee Description                                                                                Fee Amount                            
_____________________________________________________________________________________________________________________________________________________________

Prepay Claims Savings Fee
  04/24
    Prepay Claims Savings Fee
      104272-02                                                                                                     ($247.16)
      104272- Total                                                                                                 ($247.16)
    Prepay Claims Savings Fee Total                                                                                 ($247.16)
  04/24 Total                                                                                                       ($247.16)
  07/25
    Prepay Claims Savings Fee
      014267-05                                                                                                       $332.63
      014267- Total                                                                                                   $332.63
      104272-02                                                                                                        $68.78
      104272- Total                                                                                                    $68.78
    Prepay Claims Savings Fee Total                                                                                   $401.41
  07/25 Total                                                                                                         $401.41
Prepay Claims Savings Fee Total                                                                                       $154.25
                                                                                                                                                            
RadCard, MSK, Lab, RadOnc Bundle
  06/25
    RadCard, MSK, Lab, RadOnc Bundle
      014267-01                                                                                                        $51.30
      014267-03                                                                                                       $294.30
      014267-05                                                                                                       $199.80
      014267-06                                                                                                        $56.70
      014267-07                                                                                                       $162.00
      014267-08                                                                                                       $135.00
      014267-12                                                                                                         $8.10
      014267-13                                                                                                        $29.70
      014267-15                                                                                                        $27.00
      014267-19                                                                                                         $2.70
      014267-26                                                                                                        $13.50

                                                                                                                                                PAGE:3 of 6
                                                                                                                                                            
Other Claim Related Fee Description                                                                                Fee Amount                            
_____________________________________________________________________________________________________________________________________________________________
                                                                                                                                                            
      014267-34                                                                                                         $8.10
      014267-36                                                                                                        $81.00
      014267-37                                                                                                        $35.10
      014267-54                                                                                                       $199.80
      014267- Total                                                                                                 $1,304.10
      017697-00                                                                                                       $172.80
      017697-01                                                                                                        $64.80
      017697-10                                                                                                         $5.40
      017697- Total                                                                                                   $243.00
      017728-00                                                                                                        $51.30
      017728- Total                                                                                                    $51.30
      053264-01                                                                                                         $2.70
      053264- Total                                                                                                     $2.70
      104272-02                                                                                                       $361.80
      104272-09                                                                                                        $16.20
      104272-12                                                                                                        $35.10
      104272-19                                                                                                         $8.10
      104272- Total                                                                                                   $421.20
    RadCard, MSK, Lab, RadOnc Bundle Total                                                                          $2,022.30
  06/25 Total                                                                                                       $2,022.30
RadCard, MSK, Lab, RadOnc Bundle Total                                                                              $2,022.30
                                                                                                                                                            
Reprocessing Fee
  03/25
    Reprocessing Fee
      014267-54                                                                                                        $50.00
      014267- Total                                                                                                    $50.00
    Reprocessing Fee Total                                                                                             $50.00
  03/25 Total                                                                                                          $50.00
  04/25
    Reprocessing Fee
      014267-54                                                                                                        $25.00

                                                                                                                                                PAGE:4 of 6
                                                                                                                                                            
Other Claim Related Fee Description                                                                                Fee Amount                            
_____________________________________________________________________________________________________________________________________________________________
                                                                                                                                                            
      014267- Total                                                                                                    $25.00
    Reprocessing Fee Total                                                                                             $25.00
  04/25 Total                                                                                                          $25.00
  05/25
    Reprocessing Fee
      014267-54                                                                                                        $50.00
      014267- Total                                                                                                    $50.00
    Reprocessing Fee Total                                                                                             $50.00
  05/25 Total                                                                                                          $50.00
  06/25
    Reprocessing Fee
      014267-54                                                                                                        $25.00
      014267- Total                                                                                                    $25.00
    Reprocessing Fee Total                                                                                             $25.00
  06/25 Total                                                                                                          $25.00
Reprocessing Fee Total                                                                                                $150.00
                                                                                                                                                            
Utilization Management In Pat
  07/25
    Utilization Management In Pat
      014267-54                                                                                                       $110.00
      014267- Total                                                                                                   $110.00
    Utilization Management In Pat Total                                                                               $110.00
  07/25 Total                                                                                                         $110.00
Utilization Management In Pat Total                                                                                   $110.00
                                                                                                                                                            
Utilization Management Out Pat
  06/25
    Utilization Management Out Pat
      014267-03                                                                                                       $220.00
      014267-07                                                                                                       $110.00
      014267-08                                                                                                       $110.00

                                                                                                                                                PAGE:5 of 6
                                                                                                                                                            
Other Claim Related Fee Description                                                                                Fee Amount                            
_____________________________________________________________________________________________________________________________________________________________
                                                                                                                                                            
      014267-36                                                                                                       $110.00
      014267-54                                                                                                       $440.00
      014267- Total                                                                                                   $990.00
      017697-00                                                                                                       $110.00
      017697-01                                                                                                       $110.00
      017697- Total                                                                                                   $220.00
      017728-00                                                                                                       $110.00
      017728- Total                                                                                                   $110.00
      104272-02                                                                                                       $220.00
      104272- Total                                                                                                   $220.00
    Utilization Management Out Pat Total                                                                            $1,540.00
  06/25 Total                                                                                                       $1,540.00
  07/25
    Utilization Management Out Pat
      014267-01                                                                                                       $110.00
      014267-03                                                                                                       $220.00
      014267-05                                                                                                       $440.00
      014267-06                                                                                                       $110.00
      014267-07                                                                                                       $110.00
      014267-08                                                                                                       $440.00
      014267-36                                                                                                       $110.00
      014267-54                                                                                                       $110.00
      014267- Total                                                                                                 $1,650.00
      017697-00                                                                                                       $220.00
      017697- Total                                                                                                   $220.00
      017728-00                                                                                                       $220.00
      017728- Total                                                                                                   $220.00
      104272-02                                                                                                       $440.00
      104272- Total                                                                                                   $440.00
    Utilization Management Out Pat Total                                                                            $2,530.00
  07/25 Total                                                                                                       $2,530.00
Utilization Management Out Pat Total                                                                                $4,070.00

                                                                                                                                                PAGE:6 of 6
                                                                                                                                                            
Other Claim Related Fee Description                                                                                Fee Amount                            
_____________________________________________________________________________________________________________________________________________________________
                                                                                                                                                            
Other Claims Related Fee Summary Total                                                                              $8,514.77