HEALTHCARE ADJUSTMENT                                                
                                     Product/Sub Group-8 Digit/Payroll Location                                      

INVOICE NUMBER:     240806586988                                           PAGE:               1 of 2            
BILL ACCOUNT NUMBER:2695721001                                             PAID CLAIMS MONTH:  August 2024       
BILL ACCOUNT NAME:  Mid Atlantic Capital Group                             CLAIMS PAID THRU:   08/02/2024        
CLIENT NUMBER:      269572                                                 BILL CYCLE:         1 of 5            
CLIENT NAME:        Mid Atlantic Capital Group                             PREPARED DATE:      08/06/2024        

                Group                     Incurred             Provider Rate             Medical/Drug              Manual             Healthcare 
                                            Date                Adjustments                 Rebate              Adjustments           Adjustments
_____________________________________________________________________________________________________________________________________________________________
                                                                                                                                                            
Community Blue HDHP
  105188-20
                                         11/01/2023                        $                ($827.55)                     $             ($827.55)
                                         01/01/2024                        $                  ($7.26)                     $               ($7.26)
                                         02/01/2024                        $              ($7,511.66)                     $           ($7,511.66)
                                         03/01/2024                        $             ($10,213.05)                     $          ($10,213.05)
                                         04/01/2024                        $             ($24,668.18)                     $          ($24,668.18)
  105188-20 Total                                                      $0.00             ($43,227.70)                 $0.00          ($43,227.70)
Community Blue HDHP Total                                              $0.00             ($43,227.70)                 $0.00          ($43,227.70)
                                                                                                                                                            
Drug
  105188-22
                                         11/01/2023                        $              ($1,287.60)                     $           ($1,287.60)
                                         02/01/2024                        $                ($102.85)                     $             ($102.85)
                                         03/01/2024                        $             ($18,397.64)                     $          ($18,397.64)
                                         04/01/2024                        $             ($39,898.60)                     $          ($39,898.60)
  105188-22 Total                                                      $0.00             ($59,686.69)                 $0.00          ($59,686.69)
  105188-23
                                         03/01/2024                        $              ($6,828.08)                     $           ($6,828.08)
                                         04/01/2024                        $                ($225.71)                     $             ($225.71)
  105188-23 Total                                                      $0.00              ($7,053.79)                 $0.00           ($7,053.79)
  105188-26
                                         01/01/2024                        $                ($104.81)                     $             ($104.81)
                                         03/01/2024                        $              ($6,828.08)                     $           ($6,828.08)
                                         04/01/2024                        $              ($3,083.17)                     $           ($3,083.17)
  105188-26 Total                                                      $0.00             ($10,016.06)                 $0.00          ($10,016.06)
Drug Total                                                             $0.00             ($76,756.54)                 $0.00          ($76,756.54)

                                                                                                                                                PAGE:2 of 2
                                                                                                                                                            
                Group                     Incurred             Provider Rate             Medical/Drug              Manual             Healthcare 
                                            Date                Adjustments                 Rebate              Adjustments           Adjustments
_____________________________________________________________________________________________________________________________________________________________

HDHP PPO
  105188-24
                                         04/01/2024                        $              ($2,763.30)                     $           ($2,763.30)
  105188-24 Total                                                      $0.00              ($2,763.30)                 $0.00           ($2,763.30)
HDHP PPO Total                                                         $0.00              ($2,763.30)                 $0.00           ($2,763.30)
Healthcare Adjustment Total                                                                                                         ($122,747.54)