TAX ID1	TAX ID2	TAX ID3	TAX ID4	REV CODE	LEVEL OF CARE	PER DIEM	NOTE
58-2658683	81-1467358	14-1842263	75-2999825	191	Level 1	$2,026.32	Stop-loss: $95000.00 1st dollar -  reverting to 72% of billed charges.
58-2658683	81-1467358	14-1842263	75-2999825	192	Level 2	$2,307.46	Stop-loss: $95000.00 1st dollar -  reverting to 72% of billed charges.
58-2658683	81-1467358	14-1842263	75-2999825	193	Level 3	$2,588.60	Stop-loss: $95000.00 1st dollar -  reverting to 72% of billed charges.