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Item No Benefit Item No Benefit Item No Benefit Item No Benefit<br />
52033 $227.45<br />
52120 $1,023.75<br />
52366 $2,459.30<br />
52821 $1,231.20<br />
52034 $53.15<br />
52122 $1,023.75<br />
52369 $2,765.15<br />
52824 $530.25<br />
52035 $589.10<br />
52123 $1,158.90<br />
52372 $2,683.05<br />
52826 $283.95<br />
52036 $157.05<br />
52126 $1,114.20<br />
52375 $3,005.25<br />
52828 $422.25<br />
52039 $403.45<br />
52129 $1,491.55<br />
52378 $1,038.85<br />
52830 $557.00<br />
52042 $213.45<br />
52130 $547.45<br />
52379 $1,775.45<br />
52832 $763.95<br />
52045 $305.00<br />
52131 $757.20<br />
52380 $3,023.20<br />
53000 $38.80<br />
52048 $459.70<br />
52132 $308.00<br />
52382 $3,623.90<br />
53003 $109.65<br />
52051 $621.50<br />
52133 $112.65<br />
52420 $334.60<br />
53004 $42.45<br />
52054 $727.10<br />
52135 $178.55<br />
52424 $657.25<br />
53006 $621.85<br />
52055 $33.80<br />
52138 $555.00<br />
52430 $1,512.95<br />
53009 $352.75<br />
52056 $33.80<br />
52141 $549.05<br />
52440 $751.20<br />
53012 $140.20<br />
52057 $201.60<br />
52144 $511.70<br />
52442 $939.20<br />
53015 $701.00<br />
52058 $294.00<br />
52147 $482.85<br />
52444 $1,043.30<br />
53016 $576.55<br />
52059 $331.15<br />
52148 $853.60<br />
52446 $1,231.45<br />
53017 $719.20<br />
52060 $234.35<br />
52158 $1,374.35<br />
52450 $417.35<br />
53019 $692.90<br />
52061 $276.70<br />
52180 $232.90<br />
52452 $678.25<br />
53052 $146.55<br />
52062 $365.85<br />
52182 $512.65<br />
52456 $1,148.00<br />
53054 $146.55<br />
52063 $440.95<br />
52184 $757.20<br />
52458 $417.35<br />
53056 $85.80<br />
52064 $209.75<br />
52186 $932.10<br />
52460 $1,085.00<br />
53058 $146.55<br />
52066 $551.15<br />
52300 $394.55<br />
52480 $696.95<br />
53060 $119.90<br />
52069 $245.60<br />
52303 $563.50<br />
52482 $670.60<br />
53062 $107.25<br />
52072 $72.70<br />
52306 $835.90<br />
52484 $798.25<br />
53064 $194.35<br />
52073 $185.25<br />
52309 $284.00<br />
52600 $436.95<br />
53068 $162.80<br />
52075 $185.25<br />
52312 $394.55<br />
52603 $417.60<br />
53070 $212.35<br />
52078 $365.85<br />
52315 $657.40<br />
52606 $318.55<br />
53200 $72.20<br />
52081 $57.50<br />
52318 $196.00<br />
52609 $417.60<br />
53203 $141.80<br />
52084 $147.80<br />
52319 $326.75<br />
52612 $524.40<br />
53206 $170.75<br />
52087 $253.25<br />
52321 $657.40<br />
52615 $650.65<br />
53209 $1,970.35<br />
52090 $440.95<br />
52324 $657.40<br />
52618 $757.30<br />
53212 $1,064.40<br />
52092 $574.75<br />
52327 $326.15<br />
52621 $757.30<br />
53215 $488.35<br />
52094 $727.05<br />
52330 $1,085.00<br />
52624 $611.65<br />
53218 $781.15<br />
52095 $471.15<br />
52333 $1,085.00<br />
52626 $375.15<br />
53220 $393.80<br />
52096 $139.70<br />
52336 $678.25<br />
52627 $650.65<br />
53221 $1,042.20<br />
52097 $198.00<br />
52337 $1,483.50<br />
52630 $240.80<br />
53224 $1,155.35<br />
52098 $232.90<br />
52339 $772.35<br />
52633 $650.65<br />
53225 $347.05<br />
52099 $174.75<br />
52342 $1,341.50<br />
52636 $240.80<br />
53226 $373.20<br />
52102 $174.75<br />
52345 $1,512.95<br />
52800 $330.80<br />
53227 $1,419.70<br />
52105 $326.20<br />
52348 $1,709.70<br />
52803 $476.25<br />
53230 $1,599.25<br />
52106 $134.70<br />
52351 $1,920.00<br />
52806 $330.80<br />
53233 $1,797.05<br />
52108 $403.45<br />
52354 $1,946.45<br />
52809 $566.20<br />
53236 $562.35<br />
52111 $403.45<br />
52357 $2,191.35<br />
52812 $808.90<br />
53239 $562.35<br />
52114 $727.10<br />
52360 $2,235.55<br />
52815 $853.75<br />
53242 $373.20<br />
52117 $865.50<br />
52363 $2,514.95<br />
52818 $566.20<br />
53400 $160.20<br />
52033 to 53400<br />
| <strong>MediGap</strong> 2010<br />
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