pbp_a_hnumber	pbp_a_plan_identifier	segment_id	pbp_a_ben_cov	pbp_a_plan_type	orgtype	bid_id	version	pbp_c_oon_outpt_group_num_id	pbp_c_oon_outpt_grp_lbl	pbp_c_oon_outpt_bendesc_ben	pbp_c_oon_out_mc_bendesc_cats	pbp_c_oon_out_nmc_bendesc_cats	pbp_c_oon_outpt_maxplan_yn	pbp_c_oon_outpt_maxplan_amt	pbp_c_oon_outpt_coins_yn	pbp_c_oon_outpt_coins_min_pct	pbp_c_oon_outpt_coins_max_pct	pbp_c_oon_outpt_copay_yn	pbp_c_oon_outpt_copay_min_amt	pbp_c_oon_outpt_copay_max_amt	pbp_c_oon_outpt_ded_yn	pbp_c_oon_outpt_ded_amt
H0028	004	0	1	01	01	H0028_004_0	4	1														
H0028	007	0	1	01	01	H0028_007_0	5	1														
H0028	008	1	1	01	01	H0028_008_1	2	1														
H0028	008	2	1	01	01	H0028_008_2	2	1														
H0028	009	0	1	01	01	H0028_009_0	2	1														
H0088	001	0	1	04	01	H0088_001_0	4	1	35%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14d;15;16b;	7b;	2		1	35	35	2			2	
H0088	001	0	1	04	01	H0088_001_0	4	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H0088	001	0	1	04	01	H0088_001_0	4	3	OTC	10		13b;	1	13.00	2			1	0.00	0.00	2	
H0088	001	0	1	04	01	H0088_001_0	4	4	$0	11	14a;14e;	14b;14c;	2		2			1	0.00	0.00	2	
H0088	001	0	1	04	01	H0088_001_0	4	5	Dental	10		16a;16b;	2		1	20	40	2			1	100.00
H0088	001	0	1	04	01	H0088_001_0	4	6	Vision	11	17a;17b;	17a;17b;	2		1	35	50	1	0.00	0.00	2	
H0088	001	0	1	04	01	H0088_001_0	4	7	Hearing	11	18a;	18a;18b;	2		1	35	50	2			2	
H0104	012	0	1	04	01	H0104_012_0	6	1		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;16b;17a;17b;18a;	9d;14c;17a;17b;18a;	2		1	50	50	2			2	
H0104	012	0	1	04	01	H0104_012_0	6	2	Ambulance Services	01	10a;		2		2			1	200.00	200.00	2	
H0104	012	0	1	04	01	H0104_012_0	6	3		01	8a1;8a2;8b1;8b2;8b3;14e;		2		1	50	50	2			2	
H0104	012	0	1	04	01	H0104_012_0	6	4	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H0104	014	0	1	04	01	H0104_014_0	7	1		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;16b;17a;17b;18a;	9d;14c;17a;17b;18a;	2		1	50	50	2			2	
H0104	014	0	1	04	01	H0104_014_0	7	2	Ambulance Services	01	10a;		2		2			1	200.00	200.00	2	
H0104	014	0	1	04	01	H0104_014_0	7	3		01	8a1;8a2;8b1;8b2;8b3;14e;		2		1	50	50	2			2	
H0104	014	0	1	04	01	H0104_014_0	7	4	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H0104	015	0	1	04	01	H0104_015_0	4	1		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;16b;17a;17b;18a;	9d;14c;17a;17b;18a;	2		1	50	50	2			2	
H0104	015	0	1	04	01	H0104_015_0	4	2	Ambulance Services	01	10a;		2		2			1	150.00	150.00	2	
H0104	015	0	1	04	01	H0104_015_0	4	3		01	8a1;8a2;8b1;8b2;8b3;14e;		2		1	50	50	2			2	
H0104	015	0	1	04	01	H0104_015_0	4	4	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H0104	801	0	1	04	01	H0104_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
H0104	801	0	1	04	01	H0104_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0104	802	0	1	04	01	H0104_802_0	2	1		01	6;14a;		2		1	0	0	2			2	
H0104	802	0	1	04	01	H0104_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0104	804	0	1	04	01	H0104_804_0	2	1		01	6;14a;		2		1	0	0	2			2	
H0104	804	0	1	04	01	H0104_804_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0107	003	0	1	04	01	H0107_003_0	7	1	20%	01	12;		2		1	20	20	2			2	
H0107	003	0	1	04	01	H0107_003_0	7	2	$275	01	10a;		2		2			1	275.00	275.00	2	
H0107	003	0	1	04	01	H0107_003_0	7	3	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	14b;	2		1	50	50	2			2	
H0107	003	0	1	04	01	H0107_003_0	7	4	$0	10		14c;	2		2			2			2	
H0107	003	0	1	04	01	H0107_003_0	7	5	30%	01	11a;		2		1	30	30	2			2	
H0107	004	0	1	04	01	H0107_004_0	7	1	20%	01	12;		2		1	20	20	2			2	
H0107	004	0	1	04	01	H0107_004_0	7	2	$225	01	10a;		2		2			1	225.00	225.00	2	
H0107	004	0	1	04	01	H0107_004_0	7	3	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	14b;	2		1	50	50	2			2	
H0107	004	0	1	04	01	H0107_004_0	7	4	$0	10		14c;	2		2			2			2	
H0107	004	0	1	04	01	H0107_004_0	7	5	30%	01	11a;		2		1	30	30	2			2	
H0107	801	0	1	04	01	H0107_801_0	1	1		01	6;14a;		2		1	0	0	2			2	
H0107	801	0	1	04	01	H0107_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0107	802	0	1	04	01	H0107_802_0	2	1		01	6;14a;		2		1	0	0	2			2	
H0107	802	0	1	04	01	H0107_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0107	803	0	1	04	01	H0107_803_0	2	1		01	6;14a;		2		1	0	0	2			2	
H0107	803	0	1	04	01	H0107_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0111	001	0	1	04	01	H0111_001_0	4	1	10%	01	3-1;3-2;3-3;		2		1	10	10	2			2	
H0111	001	0	1	04	01	H0111_001_0	4	10	Vision	11	17a;17b;	17a;17b;	2		1	50	50	1	0.00	50.00	2	
H0111	001	0	1	04	01	H0111_001_0	4	11	Hearing	11	18a;	18a;18b;	2		1	50	50	1	50.00	50.00	2	
H0111	001	0	1	04	01	H0111_001_0	4	2	40%	01	6;8a1;8a2;8b1;8b3;9a;9b;9c;11a;11b;12;14d;15;		2		1	40	40	2			2	
H0111	001	0	1	04	01	H0111_001_0	4	3	20%	01	5;7b;9d;11c;		2		1	20	20	2			2	
H0111	001	0	1	04	01	H0111_001_0	4	4	$50	01	7a;7c;7d;7e;7f;7g;7h;7i;16b;		2		2			1	50.00	50.00	2	
H0111	001	0	1	04	01	H0111_001_0	4	5	30%	01	8b2;		2		1	30	30	2			2	
H0111	001	0	1	04	01	H0111_001_0	4	6	$300	01	10a;		2		2			1	300.00	300.00	2	
H0111	001	0	1	04	01	H0111_001_0	4	7	OTC	10		13b;	1	55.00	2			1	0.00	0.00	2	
H0111	001	0	1	04	01	H0111_001_0	4	8	$0	11	14a;14e;	14b;14c;	2		2			1	0.00	0.00	2	
H0111	001	0	1	04	01	H0111_001_0	4	9	Dental	10		16a;16b;	2		1	20	40	2			1	100.00
H0111	002	0	1	04	01	H0111_002_0	4	1	20%-50%	01	3-1;3-2;3-3;5;6;8b2;11a;11b;11c;12;14d;15;		2		1	20	50	2			2	
H0111	002	0	1	04	01	H0111_002_0	4	10	Outpatient Hospital/ASC	01	9a;9b;		2		2			1	225.00	400.00	2	
H0111	002	0	1	04	01	H0111_002_0	4	11	$300	01	10a;		2		2			1	300.00	300.00	2	
H0111	002	0	1	04	01	H0111_002_0	4	12	OTC	10		13b;	1	55.00	2			1	0.00	0.00	2	
H0111	002	0	1	04	01	H0111_002_0	4	13	Dental	10		16a;16b;	2		1	20	70	2			1	100.00
H0111	002	0	1	04	01	H0111_002_0	4	14	Vision	11	17a;17b;	17a;17b;	2		1	50	50	1	0.00	35.00	2	
H0111	002	0	1	04	01	H0111_002_0	4	15	Hearing	11	18a;	18a;18b;	2		1	50	50	1	35.00	35.00	2	
H0111	002	0	1	04	01	H0111_002_0	4	2	$5	01	7a;		2		2			1	5.00	5.00	2	
H0111	002	0	1	04	01	H0111_002_0	4	3	$20	01	7b;		2		2			1	20.00	20.00	2	
H0111	002	0	1	04	01	H0111_002_0	4	4	$40	01	7c;7e;7h;7i;9c;		2		2			1	40.00	40.00	2	
H0111	002	0	1	04	01	H0111_002_0	4	5	$35	01	7d;7f;16b;		2		2			1	35.00	35.00	2	
H0111	002	0	1	04	01	H0111_002_0	4	6	Other Healthcare Prof	01	7g;		2		2			1	5.00	50.00	2	
H0111	002	0	1	04	01	H0111_002_0	4	7	Diagnostic Proc/Test	01	8a1;		2		2			1	0.00	100.00	2	
H0111	002	0	1	04	01	H0111_002_0	4	8	$0	11	8a2;8b3;9d;14a;14e;	14b;14c;	2		2			1	0.00	0.00	2	
H0111	002	0	1	04	01	H0111_002_0	4	9	Diagnostic Radiology	01	8b1;		2		2			1	350.00	350.00	2	
H0294	002	0	1	04	01	H0294_002_0	3	1	Group 1	01	7d;		2		2			1	50.00	50.00	2	
H0294	002	0	1	04	01	H0294_002_0	3	10	Group 10	01	7c;7i;		2		2			1	40.00	40.00	2	
H0294	002	0	1	04	01	H0294_002_0	3	11	Group 11	11	7f;9d;14a;14d;14e;17b;	7f;9d;10b;14c;16b;17b;	2		2			1	0.00	0.00	2	
H0294	002	0	1	04	01	H0294_002_0	3	12	Group 12	10		18b;	2		2			1	330.00	380.00	2	
H0294	002	0	1	04	01	H0294_002_0	3	13	Group 13	01	8a2;		2		2			1	10.00	10.00	2	
H0294	002	0	1	04	01	H0294_002_0	3	14	Group 14	11	7a;18a;	18a;	2		2			1	15.00	15.00	2	
H0294	002	0	1	04	01	H0294_002_0	3	15	Group 15	01	9a;9b;		2		2			1	295.00	295.00	2	
H0294	002	0	1	04	01	H0294_002_0	3	2	Group 2	01	6;11a;		2		1	50	50	2			2	
H0294	002	0	1	04	01	H0294_002_0	3	3	Group 3	01	5;		2		2			1	55.00	55.00	2	
H0294	002	0	1	04	01	H0294_002_0	3	4	Group 4	11	3-1;3-2;3-3;7b;17a;	16a;17a;	2		2			1	20.00	20.00	2	
H0294	002	0	1	04	01	H0294_002_0	3	5	Group 5	01	7g;		2		2			1	15.00	50.00	2	
H0294	002	0	1	04	01	H0294_002_0	3	6	Group 6	01	7e;7h;9c;		2		2			1	30.00	40.00	2	
H0294	002	0	1	04	01	H0294_002_0	3	7	Group 7	01	8b3;		2		2			1	14.00	14.00	2	
H0294	002	0	1	04	01	H0294_002_0	3	8	Group 8	01	8a1;8b1;8b2;11b;11c;12;15;16b;		2		1	20	20	2			2	
H0294	002	0	1	04	01	H0294_002_0	3	9	Group 9	01	10a;		2		2			1	250.00	250.00	2	
H0294	004	0	1	04	01	H0294_004_0	3	1	Group 1	11	7d;7f;	7f;	2		2			1	50.00	50.00	2	
H0294	004	0	1	04	01	H0294_004_0	3	10	Group 10	01	7c;7i;		2		2			1	40.00	40.00	2	
H0294	004	0	1	04	01	H0294_004_0	3	11	Group 11	11	9d;14a;14d;14e;17b;	9d;14b;14c;16b;17b;	2		2			1	0.00	0.00	2	
H0294	004	0	1	04	01	H0294_004_0	3	12	Group 12	10		18b;	2		2			1	330.00	380.00	2	
H0294	004	0	1	04	01	H0294_004_0	3	13	Group 13	01	10a;		2		2			1	250.00	250.00	2	
H0294	004	0	1	04	01	H0294_004_0	3	14	Group 14	01	9a;9b;		2		2			1	335.00	335.00	2	
H0294	004	0	1	04	01	H0294_004_0	3	15	Group 15	11	7a;18a;	18a;	2		2			1	15.00	15.00	2	
H0294	004	0	1	04	01	H0294_004_0	3	2	Group 2	01	6;		2		1	50	50	2			2	
H0294	004	0	1	04	01	H0294_004_0	3	3	Group 3	01	5;		2		2			1	55.00	55.00	2	
H0294	004	0	1	04	01	H0294_004_0	3	4	Group 4	11	3-1;3-2;3-3;7b;17a;	16a;17a;	2		2			1	20.00	20.00	2	
H0294	004	0	1	04	01	H0294_004_0	3	5	Group 5	01	11a;		2		1	45	45	2			2	
H0294	004	0	1	04	01	H0294_004_0	3	6	Group 6	01	7e;7h;9c;		2		2			1	30.00	40.00	2	
H0294	004	0	1	04	01	H0294_004_0	3	7	Group 7	01	8a1;8a2;8b1;8b2;8b3;		2		1	20	20	1	10.00	14.00	2	
H0294	004	0	1	04	01	H0294_004_0	3	8	Group 8	01	11b;11c;12;15;16b;		2		1	20	20	2			2	
H0294	004	0	1	04	01	H0294_004_0	3	9	Group 9	01	7g;		2		2			1	15.00	50.00	2	
H0294	010	0	1	04	01	H0294_010_0	4	1	Group 1	01	7d;		2		2			1	50.00	50.00	2	
H0294	010	0	1	04	01	H0294_010_0	4	10	Group 10	01	7c;7i;		2		2			1	40.00	40.00	2	
H0294	010	0	1	04	01	H0294_010_0	4	11	Group 11	11	7f;9d;14a;14d;14e;17b;	7f;9d;10b;14c;16b;17b;	2		2			1	0.00	0.00	2	
H0294	010	0	1	04	01	H0294_010_0	4	12	Group 12	10		18b;	2		2			1	330.00	380.00	2	
H0294	010	0	1	04	01	H0294_010_0	4	13	Group 13	01	8a2;		2		2			1	10.00	10.00	2	
H0294	010	0	1	04	01	H0294_010_0	4	14	Group 14	11	7a;18a;	18a;	2		2			1	15.00	15.00	2	
H0294	010	0	1	04	01	H0294_010_0	4	15	Group 15	01	9a;9b;		2		2			1	295.00	295.00	2	
H0294	010	0	1	04	01	H0294_010_0	4	2	Group 2	01	6;11a;		2		1	50	50	2			2	
H0294	010	0	1	04	01	H0294_010_0	4	3	Group 3	01	5;		2		2			1	55.00	55.00	2	
H0294	010	0	1	04	01	H0294_010_0	4	4	Group 4	11	3-1;3-2;3-3;7b;17a;	16a;17a;	2		2			1	20.00	20.00	2	
H0294	010	0	1	04	01	H0294_010_0	4	5	Group 5	01	7g;		2		2			1	15.00	50.00	2	
H0294	010	0	1	04	01	H0294_010_0	4	6	Group 6	01	7e;7h;9c;		2		2			1	30.00	40.00	2	
H0294	010	0	1	04	01	H0294_010_0	4	7	Group 7	01	8b3;		2		2			1	14.00	14.00	2	
H0294	010	0	1	04	01	H0294_010_0	4	8	Group 8	01	8a1;8b1;8b2;11b;11c;12;15;16b;		2		1	20	20	2			2	
H0294	010	0	1	04	01	H0294_010_0	4	9	Group 9	01	10a;		2		2			1	250.00	250.00	2	
H0294	011	0	1	04	01	H0294_011_0	4	1	Group 1	11	7d;7f;	7f;	2		2			1	50.00	50.00	2	
H0294	011	0	1	04	01	H0294_011_0	4	10	Group 10	01	7c;7i;		2		2			1	40.00	40.00	2	
H0294	011	0	1	04	01	H0294_011_0	4	11	Group 11	11	9d;14a;14d;14e;17b;	9d;14b;14c;16b;17b;	2		2			1	0.00	0.00	2	
H0294	011	0	1	04	01	H0294_011_0	4	12	Group 12	10		18b;	2		2			1	330.00	380.00	2	
H0294	011	0	1	04	01	H0294_011_0	4	13	Group 13	01	10a;		2		2			1	250.00	250.00	2	
H0294	011	0	1	04	01	H0294_011_0	4	14	Group 14	01	9a;9b;		2		2			1	335.00	335.00	2	
H0294	011	0	1	04	01	H0294_011_0	4	15	Group 15	11	7a;18a;	18a;	2		2			1	15.00	15.00	2	
H0294	011	0	1	04	01	H0294_011_0	4	2	Group 2	01	6;		2		1	50	50	2			2	
H0294	011	0	1	04	01	H0294_011_0	4	3	Group 3	01	5;		2		2			1	55.00	55.00	2	
H0294	011	0	1	04	01	H0294_011_0	4	4	Group 4	11	3-1;3-2;3-3;7b;17a;	16a;17a;	2		2			1	20.00	20.00	2	
H0294	011	0	1	04	01	H0294_011_0	4	5	Group 5	01	11a;		2		1	45	45	2			2	
H0294	011	0	1	04	01	H0294_011_0	4	6	Group 6	01	7e;7h;9c;		2		2			1	30.00	40.00	2	
H0294	011	0	1	04	01	H0294_011_0	4	7	Group 7	01	8a1;8a2;8b1;8b2;8b3;		2		1	20	20	1	10.00	14.00	2	
H0294	011	0	1	04	01	H0294_011_0	4	8	Group 8	01	11b;11c;12;15;16b;		2		1	20	20	2			2	
H0294	011	0	1	04	01	H0294_011_0	4	9	Group 9	01	7g;		2		2			1	15.00	50.00	2	
H0294	012	0	1	04	01	H0294_012_0	4	1	Group 1	11	7c;7d;7f;7i;	7f;	2		2			1	25.00	25.00	2	
H0294	012	0	1	04	01	H0294_012_0	4	10	Group 10	01	11c;		2		1	0	20	2			2	
H0294	012	0	1	04	01	H0294_012_0	4	11	Group 11	11	7a;8a2;9d;14a;14d;14e;17a;17b;18a;	9d;14b;14c;16a;16b;17a;17b;18a;	2		2			1	0.00	0.00	2	
H0294	012	0	1	04	01	H0294_012_0	4	12	Group 12	10		18b;	2		2			1	330.00	380.00	2	
H0294	012	0	1	04	01	H0294_012_0	4	13	Group 13	01	8b1;8b2;		2		2			1	40.00	40.00	2	
H0294	012	0	1	04	01	H0294_012_0	4	14	Group 14	01	9a;9b;		2		2			1	195.00	195.00	2	
H0294	012	0	1	04	01	H0294_012_0	4	15	Group 15	10		13b;	1	60.00	2			1	0.00	0.00	2	
H0294	012	0	1	04	01	H0294_012_0	4	2	Group 2	01	6;		2		1	50	50	2			2	
H0294	012	0	1	04	01	H0294_012_0	4	3	Group 3	01	5;		2		2			1	55.00	55.00	2	
H0294	012	0	1	04	01	H0294_012_0	4	4	Group 4	01	3-1;3-2;3-3;7b;8a1;		2		2			1	20.00	20.00	2	
H0294	012	0	1	04	01	H0294_012_0	4	5	Group 5	01	7g;		2		2			1	0.00	25.00	2	
H0294	012	0	1	04	01	H0294_012_0	4	6	Group 6	01	7e;7h;9c;		2		2			1	30.00	40.00	2	
H0294	012	0	1	04	01	H0294_012_0	4	7	Group 7	01	8b3;		2		2			1	14.00	14.00	2	
H0294	012	0	1	04	01	H0294_012_0	4	8	Group 8	01	11a;11b;12;15;16b;		2		1	20	20	2			2	
H0294	012	0	1	04	01	H0294_012_0	4	9	Group 9	01	10a;		2		2			1	250.00	250.00	2	
H0710	001	0	1	04	01	H0710_001_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;	2		1	30	30	2			2	
H0710	001	0	1	04	01	H0710_001_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;	2		2			1	0.00	0.00	2	
H0710	001	0	1	04	01	H0710_001_0	4	3	Group 3	01	10a;12;		2		1	20	20	2			2	
H0710	001	0	1	04	01	H0710_001_0	4	4	Group 4	10		10b;	2		1	75	75	2			2	
H0710	001	0	1	04	01	H0710_001_0	4	5	Group 5	01	14a;		2		1	0	30	2			2	
H0710	001	0	1	04	01	H0710_001_0	4	6	Group 6	10		13b;	1	145.00	2			1	0.00	0.00	2	
H0710	004	0	1	04	01	H0710_004_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	9d;17a;18a;	2		1	30	30	2			2	
H0710	004	0	1	04	01	H0710_004_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H0710	004	0	1	04	01	H0710_004_0	4	3	Group 3	10		10b;	2		1	75	75	2			2	
H0710	004	0	1	04	01	H0710_004_0	4	4	Group 4	01	14a;		2		1	0	30	2			2	
H0710	004	0	1	04	01	H0710_004_0	4	5	Group 5	01	10a;12;		2		1	20	20	2			2	
H0710	004	0	1	04	01	H0710_004_0	4	6	Group 6	10		13b;	1	135.00	2			1	0.00	0.00	2	
H0710	005	0	1	04	01	H0710_005_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		1	30	30	2			2	
H0710	005	0	1	04	01	H0710_005_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H0710	005	0	1	04	01	H0710_005_0	4	3	Group 3	10		10b;	2		1	75	75	2			2	
H0710	005	0	1	04	01	H0710_005_0	4	4	Group 4	01	14a;		2		1	0	30	2			2	
H0710	005	0	1	04	01	H0710_005_0	4	5	Group 5	01	10a;12;		2		1	20	20	2			2	
H0710	005	0	1	04	01	H0710_005_0	4	6	Group 6	10		13b;	1	195.00	2			1	0.00	0.00	2	
H0710	006	0	1	04	01	H0710_006_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		1	30	30	2			2	
H0710	006	0	1	04	01	H0710_006_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H0710	006	0	1	04	01	H0710_006_0	4	3	Group 3	10		10b;	2		1	75	75	2			2	
H0710	006	0	1	04	01	H0710_006_0	4	4	Group 4	01	14a;		2		1	0	30	2			2	
H0710	006	0	1	04	01	H0710_006_0	4	5	Group 5	01	12;		2		1	20	20	2			2	
H0710	006	0	1	04	01	H0710_006_0	4	6	Group 6	01	10a;		2		2			1	100.00	100.00	2	
H0710	006	0	1	04	01	H0710_006_0	4	7	Group 7	10		13b;	1	30.00	2			1	0.00	0.00	2	
H0710	007	0	1	04	01	H0710_007_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		1	30	30	2			2	
H0710	007	0	1	04	01	H0710_007_0	4	2	Group 2	11	8a2;12;17b;	16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H0710	007	0	1	04	01	H0710_007_0	4	3	Group 3	10		10b;	2		1	75	75	2			2	
H0710	007	0	1	04	01	H0710_007_0	4	4	Group 4	01	14a;		2		1	0	30	2			2	
H0710	007	0	1	04	01	H0710_007_0	4	5	Group 5	01	10a;		2		2			1	75.00	75.00	2	
H0710	007	0	1	04	01	H0710_007_0	4	6	Group 6	10		13b;	1	340.00	2			1	0.00	0.00	2	
H0710	008	0	1	04	01	H0710_008_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		1	30	30	2			2	
H0710	008	0	1	04	01	H0710_008_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H0710	008	0	1	04	01	H0710_008_0	4	3	Group 3	10		10b;	2		1	75	75	2			2	
H0710	008	0	1	04	01	H0710_008_0	4	4	Group 4	01	14a;		2		1	0	30	2			2	
H0710	008	0	1	04	01	H0710_008_0	4	5	Group 5	01	12;		2		1	20	20	2			2	
H0710	008	0	1	04	01	H0710_008_0	4	6	Group 6	01	10a;		2		2			1	100.00	100.00	2	
H0710	008	0	1	04	01	H0710_008_0	4	7	Group 7	10		13b;	1	30.00	2			1	0.00	0.00	2	
H0710	009	0	1	04	01	H0710_009_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		1	30	30	2			2	
H0710	009	0	1	04	01	H0710_009_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H0710	009	0	1	04	01	H0710_009_0	4	3	Group 3	10		10b;	2		1	75	75	2			2	
H0710	009	0	1	04	01	H0710_009_0	4	4	Group 4	01	14a;		2		1	0	30	2			2	
H0710	009	0	1	04	01	H0710_009_0	4	5	Group 5	01	12;		2		1	20	20	2			2	
H0710	009	0	1	04	01	H0710_009_0	4	6	Group 6	01	10a;		2		2			1	100.00	100.00	2	
H0710	009	0	1	04	01	H0710_009_0	4	7	Group 7	10		13b;	1	30.00	2			1	0.00	0.00	2	
H0710	010	0	1	04	01	H0710_010_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;	2		1	30	30	2			2	
H0710	010	0	1	04	01	H0710_010_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;	2		2			1	0.00	0.00	2	
H0710	010	0	1	04	01	H0710_010_0	4	3	Group 3	01	10a;12;		2		1	20	20	2			2	
H0710	010	0	1	04	01	H0710_010_0	4	4	Group 4	10		10b;	2		1	75	75	2			2	
H0710	010	0	1	04	01	H0710_010_0	4	5	Group 5	01	14a;		2		1	0	30	2			2	
H0710	010	0	1	04	01	H0710_010_0	4	6	Group 6	10		13b;	1	130.00	2			1	0.00	0.00	2	
H0710	012	0	1	04	01	H0710_012_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		1	30	30	2			2	
H0710	012	0	1	04	01	H0710_012_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H0710	012	0	1	04	01	H0710_012_0	4	3	Group 3	10		10b;	2		1	75	75	2			2	
H0710	012	0	1	04	01	H0710_012_0	4	4	Group 4	01	14a;		2		1	0	30	2			2	
H0710	012	0	1	04	01	H0710_012_0	4	5	Group 5	01	12;		2		1	20	20	2			2	
H0710	012	0	1	04	01	H0710_012_0	4	6	Group 6	01	10a;		2		2			1	100.00	100.00	2	
H0710	012	0	1	04	01	H0710_012_0	4	7	Group 7	10		13b;	1	30.00	2			1	0.00	0.00	2	
H0710	013	0	1	04	01	H0710_013_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;18a;	2		1	30	30	2			2	
H0710	013	0	1	04	01	H0710_013_0	4	2	Group 2	11	8a2;17b;	18b;	2		2			1	0.00	0.00	2	
H0710	013	0	1	04	01	H0710_013_0	4	3	Group 3	01	10a;12;		2		1	20	20	2			2	
H0710	013	0	1	04	01	H0710_013_0	4	4	Group 4	10		10b;	2		1	75	75	2			2	
H0710	013	0	1	04	01	H0710_013_0	4	5	Group 5	01	14a;		2		1	0	30	2			2	
H0710	013	0	1	04	01	H0710_013_0	4	6	Group 6	10		13b;	1	120.00	2			1	0.00	0.00	2	
H0710	015	0	1	04	01	H0710_015_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		1	30	30	2			2	
H0710	015	0	1	04	01	H0710_015_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H0710	015	0	1	04	01	H0710_015_0	4	3	Group 3	01	10a;12;		2		1	20	20	2			2	
H0710	015	0	1	04	01	H0710_015_0	4	4	Group 4	10		10b;	2		1	75	75	2			2	
H0710	015	0	1	04	01	H0710_015_0	4	5	Group 5	01	14a;		2		1	0	30	2			2	
H0710	015	0	1	04	01	H0710_015_0	4	6	Group 6	10		13b;	1	70.00	2			1	0.00	0.00	2	
H0710	016	0	1	04	01	H0710_016_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		1	30	30	2			2	
H0710	016	0	1	04	01	H0710_016_0	4	2	Group 2	11	8a2;17b;	17b;18b;	2		2			1	0.00	0.00	2	
H0710	016	0	1	04	01	H0710_016_0	4	3	Group 3	01	10a;12;		2		1	20	20	2			2	
H0710	016	0	1	04	01	H0710_016_0	4	4	Group 4	10		10b;	2		1	75	75	2			2	
H0710	016	0	1	04	01	H0710_016_0	4	5	Group 5	01	14a;		2		1	0	30	2			2	
H0710	016	0	1	04	01	H0710_016_0	4	6	Group 6	10		13b;	1	155.00	2			1	0.00	0.00	2	
H0710	017	0	1	04	01	H0710_017_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		1	30	30	2			2	
H0710	017	0	1	04	01	H0710_017_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H0710	017	0	1	04	01	H0710_017_0	4	3	Group 3	01	10a;12;		2		1	20	20	2			2	
H0710	017	0	1	04	01	H0710_017_0	4	4	Group 4	10		10b;	2		1	75	75	2			2	
H0710	017	0	1	04	01	H0710_017_0	4	5	Group 5	01	14a;		2		1	0	30	2			2	
H0710	017	0	1	04	01	H0710_017_0	4	6	Group 6	10		13b;	1	90.00	2			1	0.00	0.00	2	
H0710	018	0	1	04	01	H0710_018_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;	2		1	30	30	2			2	
H0710	018	0	1	04	01	H0710_018_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;	2		2			1	0.00	0.00	2	
H0710	018	0	1	04	01	H0710_018_0	4	3	Group 3	10		10b;	2		1	75	75	2			2	
H0710	018	0	1	04	01	H0710_018_0	4	4	Group 4	01	14a;		2		1	0	30	2			2	
H0710	018	0	1	04	01	H0710_018_0	4	5	Group 5	01	12;		2		1	20	20	2			2	
H0710	018	0	1	04	01	H0710_018_0	4	6	Group 6	01	10a;		2		2			1	100.00	100.00	2	
H0710	018	0	1	04	01	H0710_018_0	4	7	Group 7	10		13b;	1	30.00	2			1	0.00	0.00	2	
H0710	020	0	1	04	01	H0710_020_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;	2		1	30	30	2			2	
H0710	020	0	1	04	01	H0710_020_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;	2		2			1	0.00	0.00	2	
H0710	020	0	1	04	01	H0710_020_0	4	3	Group 3	01	10a;12;		2		1	20	20	2			2	
H0710	020	0	1	04	01	H0710_020_0	4	4	Group 4	10		10b;	2		1	75	75	2			2	
H0710	020	0	1	04	01	H0710_020_0	4	5	Group 5	01	14a;		2		1	0	30	2			2	
H0710	020	0	1	04	01	H0710_020_0	4	6	Group 6	10		13b;	1	70.00	2			1	0.00	0.00	2	
H0710	026	0	1	04	01	H0710_026_0	5	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		1	30	30	2			2	
H0710	026	0	1	04	01	H0710_026_0	5	2	Group 2	11	8a2;17b;	17b;18b;	2		2			1	0.00	0.00	2	
H0710	026	0	1	04	01	H0710_026_0	5	3	Group 3	10		10b;	2		1	75	75	2			2	
H0710	026	0	1	04	01	H0710_026_0	5	4	Group 4	01	14a;		2		1	0	30	2			2	
H0710	026	0	1	04	01	H0710_026_0	5	5	Group 5	01	10a;12;		2		1	20	20	2			2	
H0710	026	0	1	04	01	H0710_026_0	5	6	Group 6	10		13b;	1	65.00	2			1	0.00	0.00	2	
H0710	027	0	1	04	01	H0710_027_0	5	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;	2		1	30	30	2			2	
H0710	027	0	1	04	01	H0710_027_0	5	2	Group 2	11	8a2;17b;	16a;16b;17b;	2		2			1	0.00	0.00	2	
H0710	027	0	1	04	01	H0710_027_0	5	3	Group 3	01	10a;12;		2		1	20	20	2			2	
H0710	027	0	1	04	01	H0710_027_0	5	4	Group 4	10		10b;	2		1	75	75	2			2	
H0710	027	0	1	04	01	H0710_027_0	5	5	Group 5	01	14a;		2		1	0	30	2			2	
H0710	027	0	1	04	01	H0710_027_0	5	6	Group 6	10		13b;	1	265.00	2			1	0.00	0.00	2	
H0710	030	0	1	04	01	H0710_030_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		1	30	30	2			2	
H0710	030	0	1	04	01	H0710_030_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H0710	030	0	1	04	01	H0710_030_0	4	3	Group 3	10		10b;	2		1	75	75	2			2	
H0710	030	0	1	04	01	H0710_030_0	4	4	Group 4	01	14a;		2		1	0	30	2			2	
H0710	030	0	1	04	01	H0710_030_0	4	5	Group 5	01	12;		2		1	20	20	2			2	
H0710	030	0	1	04	01	H0710_030_0	4	6	Group 6	01	10a;		2		2			1	100.00	100.00	2	
H0710	030	0	1	04	01	H0710_030_0	4	7	Group 7	10		13b;	1	30.00	2			1	0.00	0.00	2	
H0710	031	0	1	04	01	H0710_031_0	5	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	9d;17a;18a;	2		1	30	30	2			2	
H0710	031	0	1	04	01	H0710_031_0	5	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H0710	031	0	1	04	01	H0710_031_0	5	3	Group 3	01	10a;12;		2		1	20	20	2			2	
H0710	031	0	1	04	01	H0710_031_0	5	4	Group 4	10		10b;	2		1	75	75	2			2	
H0710	031	0	1	04	01	H0710_031_0	5	5	Group 5	01	14a;		2		1	0	30	2			2	
H0710	031	0	1	04	01	H0710_031_0	5	6	Group 6	10		13b;	1	130.00	2			1	0.00	0.00	2	
H0710	032	0	1	04	01	H0710_032_0	5	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;	2		1	30	30	2			2	
H0710	032	0	1	04	01	H0710_032_0	5	2	Group 2	11	8a2;17b;	16a;16b;17b;	2		2			1	0.00	0.00	2	
H0710	032	0	1	04	01	H0710_032_0	5	3	Group 3	01	10a;12;		2		1	20	20	2			2	
H0710	032	0	1	04	01	H0710_032_0	5	4	Group 4	10		10b;	2		1	75	75	2			2	
H0710	032	0	1	04	01	H0710_032_0	5	5	Group 5	01	14a;		2		1	0	30	2			2	
H0710	032	0	1	04	01	H0710_032_0	5	6	Group 6	10		13b;	1	50.00	2			1	0.00	0.00	2	
H0710	033	0	1	04	01	H0710_033_0	5	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		1	30	30	2			2	
H0710	033	0	1	04	01	H0710_033_0	5	2	Group 2	11	8a2;17b;	17b;18b;	2		2			1	0.00	0.00	2	
H0710	033	0	1	04	01	H0710_033_0	5	3	Group 3	01	10a;12;		2		1	20	20	2			2	
H0710	033	0	1	04	01	H0710_033_0	5	4	Group 4	10		10b;	2		1	75	75	2			2	
H0710	033	0	1	04	01	H0710_033_0	5	5	Group 5	01	14a;		2		1	0	30	2			2	
H0710	033	0	1	04	01	H0710_033_0	5	6	Group 6	10		13b;	1	95.00	2			1	0.00	0.00	2	
H0710	034	0	1	04	01	H0710_034_0	5	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		1	30	30	2			2	
H0710	034	0	1	04	01	H0710_034_0	5	2	Group 2	11	8a2;17b;	17b;18b;	2		2			1	0.00	0.00	2	
H0710	034	0	1	04	01	H0710_034_0	5	3	Group 3	10		10b;	2		1	75	75	2			2	
H0710	034	0	1	04	01	H0710_034_0	5	4	Group 4	01	14a;		2		1	0	30	2			2	
H0710	034	0	1	04	01	H0710_034_0	5	5	Group 5	01	10a;12;		2		1	20	20	2			2	
H0710	034	0	1	04	01	H0710_034_0	5	6	Group 6	10		13b;	1	100.00	2			1	0.00	0.00	2	
H0710	035	0	1	04	01	H0710_035_0	5	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;	2		1	30	30	2			2	
H0710	035	0	1	04	01	H0710_035_0	5	2	Group 2	11	8a2;17b;	17b;	2		2			1	0.00	0.00	2	
H0710	035	0	1	04	01	H0710_035_0	5	3	Group 3	01	10a;12;		2		1	20	20	2			2	
H0710	035	0	1	04	01	H0710_035_0	5	4	Group 4	10		10b;	2		1	75	75	2			2	
H0710	035	0	1	04	01	H0710_035_0	5	5	Group 5	01	14a;		2		1	0	30	2			2	
H0710	035	0	1	04	01	H0710_035_0	5	6	Group 6	10		13b;	1	75.00	2			1	0.00	0.00	2	
H0710	036	0	1	04	01	H0710_036_0	5	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		1	30	30	2			2	
H0710	036	0	1	04	01	H0710_036_0	5	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H0710	036	0	1	04	01	H0710_036_0	5	3	Group 3	01	10a;12;		2		1	20	20	2			2	
H0710	036	0	1	04	01	H0710_036_0	5	4	Group 4	10		10b;	2		1	75	75	2			2	
H0710	036	0	1	04	01	H0710_036_0	5	5	Group 5	01	14a;		2		1	0	30	2			2	
H0710	037	0	1	04	01	H0710_037_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		1	30	30	2			2	
H0710	037	0	1	04	01	H0710_037_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H0710	037	0	1	04	01	H0710_037_0	4	3	Group 3	10		10b;	2		1	75	75	2			2	
H0710	037	0	1	04	01	H0710_037_0	4	4	Group 4	01	14a;		2		1	0	30	2			2	
H0710	037	0	1	04	01	H0710_037_0	4	5	Group 5	01	12;		2		1	20	20	2			2	
H0710	037	0	1	04	01	H0710_037_0	4	6	Group 6	01	10a;		2		2			1	100.00	100.00	2	
H0710	037	0	1	04	01	H0710_037_0	4	7	Group 7	10		13b;	1	40.00	2			1	0.00	0.00	2	
H0710	038	0	1	04	01	H0710_038_0	5	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;	2		1	30	30	2			2	
H0710	038	0	1	04	01	H0710_038_0	5	2	Group 2	11	8a2;17b;	16a;16b;17b;	2		2			1	0.00	0.00	2	
H0710	038	0	1	04	01	H0710_038_0	5	3	Group 3	01	10a;12;		2		1	20	20	2			2	
H0710	038	0	1	04	01	H0710_038_0	5	4	Group 4	10		10b;	2		1	75	75	2			2	
H0710	038	0	1	04	01	H0710_038_0	5	5	Group 5	01	14a;		2		1	0	30	2			2	
H0710	038	0	1	04	01	H0710_038_0	5	6	Group 6	10		13b;	1	135.00	2			1	0.00	0.00	2	
H0710	801	0	1	04	01	H0710_801_0	1	1		01	6;14a;		2		1	0	0	2			2	
H0710	801	0	1	04	01	H0710_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0710	802	0	1	04	01	H0710_802_0	1	1		01	6;14a;		2		1	0	0	2			2	
H0710	802	0	1	04	01	H0710_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0710	803	0	1	04	01	H0710_803_0	1	1		01	6;14a;		2		1	0	0	2			2	
H0710	803	0	1	04	01	H0710_803_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0710	804	0	2	04	01	H0710_804_0	1	1		01	6;14a;		2		1	0	0	2			2	
H0710	804	0	2	04	01	H0710_804_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0710	805	0	2	04	01	H0710_805_0	1	1		01	6;14a;		2		1	0	0	2			2	
H0710	805	0	2	04	01	H0710_805_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0710	806	0	2	04	01	H0710_806_0	1	1		01	6;14a;		2		1	0	0	2			2	
H0710	806	0	2	04	01	H0710_806_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0710	807	0	1	04	01	H0710_807_0	1	1		01	6;14a;		2		1	0	0	2			2	
H0710	807	0	1	04	01	H0710_807_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0710	808	0	1	04	01	H0710_808_0	1	1		01	6;14a;		2		1	0	0	2			2	
H0710	808	0	1	04	01	H0710_808_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0710	809	0	1	04	01	H0710_809_0	1	1		01	6;14a;		2		1	0	0	2			2	
H0710	809	0	1	04	01	H0710_809_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0710	810	0	1	04	01	H0710_810_0	1	1		01	6;14a;		2		1	0	0	2			2	
H0710	810	0	1	04	01	H0710_810_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0710	811	0	1	04	01	H0710_811_0	1	1		01	6;14a;		2		1	0	0	2			2	
H0710	811	0	1	04	01	H0710_811_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0710	812	0	2	04	01	H0710_812_0	1	1		01	6;14a;		2		1	0	0	2			2	
H0710	812	0	2	04	01	H0710_812_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0710	813	0	2	04	01	H0710_813_0	1	1		01	6;14a;		2		1	0	0	2			2	
H0710	813	0	2	04	01	H0710_813_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0710	814	0	2	04	01	H0710_814_0	1	1		01	6;14a;		2		1	0	0	2			2	
H0710	814	0	2	04	01	H0710_814_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0710	815	0	1	04	01	H0710_815_0	1	1		01	6;14a;		2		1	0	0	2			2	
H0710	815	0	1	04	01	H0710_815_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0710	816	0	1	04	01	H0710_816_0	1	1		01	6;14a;		2		1	0	0	2			2	
H0710	816	0	1	04	01	H0710_816_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0710	817	0	1	04	01	H0710_817_0	2	1		01	6;14a;		2		1	0	0	2			2	
H0710	817	0	1	04	01	H0710_817_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0710	818	0	1	04	01	H0710_818_0	2	1		01	6;14a;		2		1	0	0	2			2	
H0710	818	0	1	04	01	H0710_818_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0710	819	0	1	04	01	H0710_819_0	1	1		01	6;14a;		2		1	0	0	2			2	
H0710	819	0	1	04	01	H0710_819_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0710	820	0	1	04	01	H0710_820_0	1	1		01	6;14a;		2		1	0	0	2			2	
H0710	820	0	1	04	01	H0710_820_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0710	821	0	1	04	01	H0710_821_0	1	1		01	6;14a;		2		1	0	0	2			2	
H0710	821	0	1	04	01	H0710_821_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0710	822	0	1	04	01	H0710_822_0	1	1		01	6;14a;		2		1	0	0	2			2	
H0710	822	0	1	04	01	H0710_822_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0710	823	0	1	04	01	H0710_823_0	1	1		01	6;14a;		2		1	0	0	2			2	
H0710	823	0	1	04	01	H0710_823_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H0735	001	0	1	04	01	H0735_001_0	10	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	25	25	2			2	
H0735	001	0	1	04	01	H0735_001_0	10	2	Group 2	11	8a2;12;	13b;16a;	2		2			2			2	
H0735	001	0	1	04	01	H0735_001_0	10	3	Group 3	01	10a;		2		2			1	200.00	200.00	2	
H0735	001	0	1	04	01	H0735_001_0	10	4		10		14c;	1	20.00	2			2			2	
H0735	002	0	1	04	01	H0735_002_0	9	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	20	20	2			2	
H0735	002	0	1	04	01	H0735_002_0	9	2	Group 2	11	8a2;12;	13b;16a;	2		2			2			2	
H0735	002	0	1	04	01	H0735_002_0	9	3	Group 3	01	10a;		2		2			1	100.00	100.00	2	
H0735	002	0	1	04	01	H0735_002_0	9	4		10		14c;	1	20.00	2			2			2	
H1019	001	0	1	01	01	H1019_001_0	2	1														
H1019	006	0	1	01	01	H1019_006_0	2	1														
H1019	023	0	1	01	01	H1019_023_0	4	1														
H1019	024	0	1	01	01	H1019_024_0	4	1														
H1019	026	0	1	01	01	H1019_026_0	5	1														
H1019	028	0	1	01	01	H1019_028_0	4	1														
H1019	043	0	1	01	01	H1019_043_0	2	1														
H1019	054	0	1	01	01	H1019_054_0	2	1														
H1019	057	0	1	01	01	H1019_057_0	2	1														
H1019	060	0	1	01	01	H1019_060_0	2	1														
H1019	065	0	1	01	01	H1019_065_0	2	1														
H1019	069	0	1	01	01	H1019_069_0	3	1														
H1019	073	0	1	01	01	H1019_073_0	4	1														
H1019	076	0	1	01	01	H1019_076_0	2	1														
H1019	077	0	1	01	01	H1019_077_0	3	1														
H1019	079	0	1	01	01	H1019_079_0	3	1														
H1019	081	0	1	01	01	H1019_081_0	4	1														
H1019	083	0	1	01	01	H1019_083_0	4	1														
H1019	085	0	1	01	01	H1019_085_0	3	1														
H1019	089	0	1	01	01	H1019_089_0	3	1														
H1019	090	0	1	01	01	H1019_090_0	5	1														
H1019	091	0	1	01	01	H1019_091_0	3	1														
H1019	092	0	1	01	01	H1019_092_0	2	1														
H1019	094	0	1	01	01	H1019_094_0	2	1														
H1036	025	0	1	01	01	H1036_025_0	2	1														
H1036	044	0	1	01	01	H1036_044_0	3	1														
H1036	054	0	1	01	01	H1036_054_0	4	1														
H1036	056	0	1	01	01	H1036_056_0	3	1														
H1036	062	0	1	01	01	H1036_062_0	3	1														
H1036	065	0	1	01	01	H1036_065_0	3	1														
H1036	067	0	1	01	01	H1036_067_0	3	1														
H1036	068	0	1	01	01	H1036_068_0	3	1														
H1036	074	0	1	01	01	H1036_074_0	3	1														
H1036	077	0	1	01	01	H1036_077_0	5	1														
H1036	081	0	1	01	01	H1036_081_0	3	1														
H1036	102	0	1	01	01	H1036_102_0	5	1														
H1036	103	0	1	01	01	H1036_103_0	4	1														
H1036	104	0	1	01	01	H1036_104_0	4	1														
H1036	119	0	1	01	01	H1036_119_0	3	1														
H1036	121	0	1	01	01	H1036_121_0	3	1														
H1036	130	0	1	01	01	H1036_130_0	2	1														
H1036	137	0	1	01	01	H1036_137_0	4	1														
H1036	138	0	1	01	01	H1036_138_0	2	1														
H1036	140	0	1	01	01	H1036_140_0	3	1														
H1036	143	0	1	01	01	H1036_143_0	3	1														
H1036	146	0	1	01	01	H1036_146_0	2	1														
H1036	151	0	1	01	01	H1036_151_0	5	1														
H1036	153	0	1	01	01	H1036_153_0	6	1														
H1036	156	0	1	01	01	H1036_156_0	4	1														
H1036	157	0	1	01	01	H1036_157_0	3	1														
H1036	160	0	1	01	01	H1036_160_0	3	1														
H1036	167	0	1	01	01	H1036_167_0	3	1														
H1036	168	0	1	01	01	H1036_168_0	2	1														
H1036	171	0	1	01	01	H1036_171_0	3	1														
H1036	175	0	1	01	01	H1036_175_0	4	1														
H1036	199	0	1	01	01	H1036_199_0	3	1														
H1036	209	0	1	01	01	H1036_209_0	5	1														
H1036	210	0	1	01	01	H1036_210_0	5	1														
H1036	213	0	1	01	01	H1036_213_0	5	1														
H1036	214	0	1	01	01	H1036_214_0	4	1														
H1036	215	0	1	01	01	H1036_215_0	2	1														
H1036	217	0	1	01	01	H1036_217_0	2	1														
H1036	219	0	1	01	01	H1036_219_0	6	1														
H1036	222	0	1	01	01	H1036_222_0	4	1														
H1036	223	0	1	01	01	H1036_223_0	4	1														
H1036	226	0	1	01	01	H1036_226_0	4	1														
H1036	229	0	1	01	01	H1036_229_0	2	1														
H1036	230	0	1	01	01	H1036_230_0	3	1														
H1036	231	0	1	01	01	H1036_231_0	5	1														
H1036	233	0	1	01	01	H1036_233_0	3	1														
H1036	234	0	1	01	01	H1036_234_0	6	1														
H1036	235	0	1	01	01	H1036_235_0	5	1														
H1036	236	0	1	01	01	H1036_236_0	3	1														
H1036	237	1	1	01	01	H1036_237_1	2	1														
H1036	237	2	1	01	01	H1036_237_2	3	1														
H1036	241	0	1	01	01	H1036_241_0	3	1														
H1036	243	0	1	01	01	H1036_243_0	3	1														
H1036	245	0	1	01	01	H1036_245_0	3	1														
H1036	247	0	1	01	01	H1036_247_0	3	1														
H1036	249	0	1	01	01	H1036_249_0	3	1														
H1036	251	0	1	01	01	H1036_251_0	3	1														
H1036	253	0	1	01	01	H1036_253_0	3	1														
H1036	255	0	1	01	01	H1036_255_0	3	1														
H1036	257	0	1	01	01	H1036_257_0	3	1														
H1036	259	0	1	01	01	H1036_259_0	3	1														
H1036	261	0	1	01	01	H1036_261_0	4	1														
H1036	262	0	1	01	01	H1036_262_0	3	1														
H1036	263	0	1	01	01	H1036_263_0	2	1														
H1036	264	0	1	01	01	H1036_264_0	5	1														
H1036	265	1	1	01	01	H1036_265_1	2	1														
H1036	265	2	1	01	01	H1036_265_2	2	1														
H1036	266	0	1	01	01	H1036_266_0	2	1														
H1036	267	0	1	01	01	H1036_267_0	2	1														
H1036	268	0	1	01	01	H1036_268_0	2	1														
H1036	269	0	1	01	01	H1036_269_0	2	1														
H1036	270	0	1	01	01	H1036_270_0	2	1														
H1036	271	0	1	01	01	H1036_271_0	2	1														
H1036	274	0	1	01	01	H1036_274_0	3	1														
H1100	001	0	1	04	01	H1100_001_0	5	1	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H1100	001	0	1	04	01	H1100_001_0	5	2	$400	01	10a;		2		2			1	400.00	400.00	2	
H1100	001	0	1	04	01	H1100_001_0	5	3	20%	01	11a;11b;12;		2		1	20	20	2			2	
H1100	001	0	1	04	01	H1100_001_0	5	4	0%	11	14d;	14c;16a;16b;	2		1	0	0	2			2	
H1100	001	0	1	04	01	H1100_001_0	5	5	0%-50%	01	14a;		2		1	0	50	2			2	
H1100	001	0	1	04	01	H1100_001_0	5	6	0%-20%	01	11c;		2		1	0	20	2			2	
H1302	004	0	1	04	01	H1302_004_0	2	1	No Cost Share	01	14a;14d;14e;17a;17b;		2		2			2			2	
H1302	004	0	1	04	01	H1302_004_0	2	10	Eye Exams	10		17a;	2		2			1	20.00	20.00	2	
H1302	004	0	1	04	01	H1302_004_0	2	2	$30 Copay	01	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;		2		2			1	30.00	30.00	2	
H1302	004	0	1	04	01	H1302_004_0	2	3	Ambulance $175 Copayment	01	10a;		2		2			1	175.00	175.00	2	
H1302	004	0	1	04	01	H1302_004_0	2	4	30% Coinsurance	01	15;		2		1	30	30	2			2	
H1302	004	0	1	04	01	H1302_004_0	2	5	20% Coinsurance	01	6;9a;9b;11a;11b;11c;12;		2		1	20	20	2			2	
H1302	004	0	1	04	01	H1302_004_0	2	6	25% Coinsurance	11	5;7e;7h;8a1;8a2;8b1;8b2;8b3;9c;9d;16b;	9d;	2		1	25	25	2			2	
H1302	004	0	1	04	01	H1302_004_0	2	7	Vision Eyewear	10		17b;	2		2			1	35.00	35.00	2	
H1302	004	0	1	04	01	H1302_004_0	2	8	$0 to $10 Copayment	10		14c;	2		2			1	0.00	10.00	2	
H1302	004	0	1	04	01	H1302_004_0	2	9	Hearing Aids	11	18a;	18a;18b;	2		2			1	699.00	999.00	2	
H1304	001	0	1	04	01	H1304_001_0	8	1	Routine Eye Exam and Eyewear	10		17a;17b;	2		2			1	0.00	0.00	2	
H1304	001	0	1	04	01	H1304_001_0	8	2	Eligible Supplemental Benefits	10		14c;	2		2			1	0.00	0.00	2	
H1304	001	0	1	04	01	H1304_001_0	8	3	Ambulance Services	01	10a;		2		2			1	275.00	275.00	2	
H1304	001	0	1	04	01	H1304_001_0	8	4	All Other OON 50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;16a;	2		1	50	50	2			2	
H1304	002	0	1	04	01	H1304_002_0	9	1	Routine Eye Exam and Eyewear	10		17a;17b;	2		2			1	0.00	0.00	2	
H1304	002	0	1	04	01	H1304_002_0	9	2	Eligible Supplemental Benefits	10		14c;	2		2			1	0.00	0.00	2	
H1304	002	0	1	04	01	H1304_002_0	9	3	Ambulance Services	01	10a;		2		2			1	275.00	275.00	2	
H1304	002	0	1	04	01	H1304_002_0	9	4	All Other OON 50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;16a;	2		1	50	50	2			2	
H1304	004	0	1	04	01	H1304_004_0	10	1	Routine Eye Exam and Eyewear	10		17a;17b;	2		2			1	0.00	0.00	2	
H1304	004	0	1	04	01	H1304_004_0	10	2	Eligible Supplemental Benefits	10		14c;	2		2			1	0.00	0.00	2	
H1304	004	0	1	04	01	H1304_004_0	10	3	Ambulance Services	01	10a;		2		2			1	250.00	250.00	2	
H1304	004	0	1	04	01	H1304_004_0	10	4	All Other OON 50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;16a;16b;	2		1	50	50	2			2	
H1304	004	0	1	04	01	H1304_004_0	10	5	Hearing Exams	10		18a;	2		2			1	150.00	150.00	2	
H1304	004	0	1	04	01	H1304_004_0	10	6	Hearing Aids	10		18b;	2		2			1	599.00	899.00	2	
H1304	008	0	1	04	01	H1304_008_0	8	1	Routine Eye Exam and Eyewear	10		17a;17b;	2		2			1	0.00	0.00	2	
H1304	008	0	1	04	01	H1304_008_0	8	2	Eligible Supplemental Benefits	10		14c;	2		2			1	0.00	0.00	2	
H1304	008	0	1	04	01	H1304_008_0	8	3	Ambulance Services	01	10a;		2		2			1	275.00	275.00	2	
H1304	008	0	1	04	01	H1304_008_0	8	4	All Other OON 50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;16a;	2		1	50	50	2			2	
H1304	009	0	1	04	01	H1304_009_0	9	1	Routine Eye Exam and Eyewear	10		17a;17b;	2		2			1	0.00	0.00	2	
H1304	009	0	1	04	01	H1304_009_0	9	2	Eligible Supplemental Benefits	10		14c;	2		2			1	0.00	0.00	2	
H1304	009	0	1	04	01	H1304_009_0	9	3	Ambulance Services	01	10a;		2		2			1	275.00	275.00	2	
H1304	009	0	1	04	01	H1304_009_0	9	4	All Other OON 50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;16a;	2		1	50	50	2			2	
H1304	010	0	1	04	01	H1304_010_0	8	1	Routine Eye Exam and Eyewear	10		17a;17b;	2		2			1	0.00	0.00	2	
H1304	010	0	1	04	01	H1304_010_0	8	2	Eligible Supplemental Benefits	10		14c;	2		2			1	0.00	0.00	2	
H1304	010	0	1	04	01	H1304_010_0	8	3	Ambulance Services	01	10a;		2		2			1	250.00	250.00	2	
H1304	010	0	1	04	01	H1304_010_0	8	4	All Other OON 50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;16a;16b;	2		1	50	50	2			2	
H1304	010	0	1	04	01	H1304_010_0	8	5	Hearing Exams	10		18a;	2		2			1	150.00	150.00	2	
H1304	010	0	1	04	01	H1304_010_0	8	6	Hearing Aids	10		18b;	2		2			1	599.00	899.00	2	
H1304	803	0	1	04	01	H1304_803_0	3	1		01	6;14a;		2		1	0	0	2			2	
H1304	803	0	1	04	01	H1304_803_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1304	804	0	1	04	01	H1304_804_0	3	1		01	6;14a;		2		1	0	0	2			2	
H1304	804	0	1	04	01	H1304_804_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1365	001	0	1	04	01	H1365_001_0	4	1	1	11	3-1;3-2;3-3;5;7b;7c;7d;7e;7f;7g;7h;7i;8b1;8b2;9a;9b;9c;9d;11a;11b;14a;16b;17a;17b;18a;	14b;17a;	2		1	30	30	2			2	
H1365	001	0	1	04	01	H1365_001_0	4	10	10	10		13a;	1	200.00	2			2			2	
H1365	001	0	1	04	01	H1365_001_0	4	2	2	01	6;11c;12;15;		2		1	20	20	2			2	
H1365	001	0	1	04	01	H1365_001_0	4	3	3	01	8a1;		2		1	0	15	2			2	
H1365	001	0	1	04	01	H1365_001_0	4	4	4	01	8a2;		2		1	0	20	2			2	
H1365	001	0	1	04	01	H1365_001_0	4	5	5	01	14d;14e;		2		2			2			2	
H1365	001	0	1	04	01	H1365_001_0	4	6	6	01	10a;		2		2			1	250.00	250.00	2	
H1365	001	0	1	04	01	H1365_001_0	4	7	7	01	7a;		2		2			1	25.00	25.00	2	
H1365	001	0	1	04	01	H1365_001_0	4	8	8	01	8b3;		2		1	15	15	2			2	
H1365	001	0	1	04	01	H1365_001_0	4	9	9	10		14c;	1	350.00	2			2			2	
H1365	002	0	1	04	01	H1365_002_0	4	1	1	11	3-1;3-2;3-3;5;7b;7c;7d;7e;7f;7g;7h;7i;8b1;8b2;9a;9b;9c;9d;11a;11b;14a;16b;17a;17b;18a;	14b;17a;	2		1	30	30	2			2	
H1365	002	0	1	04	01	H1365_002_0	4	10	10	10		13a;	1	200.00	2			2			2	
H1365	002	0	1	04	01	H1365_002_0	4	2	2	01	6;11c;12;15;		2		1	20	20	2			2	
H1365	002	0	1	04	01	H1365_002_0	4	3	3	01	8a1;		2		1	0	15	2			2	
H1365	002	0	1	04	01	H1365_002_0	4	4	4	01	8a2;		2		1	0	20	2			2	
H1365	002	0	1	04	01	H1365_002_0	4	5	5	01	14d;14e;		2		2			2			2	
H1365	002	0	1	04	01	H1365_002_0	4	6	6	01	10a;		2		2			1	250.00	250.00	2	
H1365	002	0	1	04	01	H1365_002_0	4	7	7	01	7a;		2		2			1	25.00	25.00	2	
H1365	002	0	1	04	01	H1365_002_0	4	8	8	01	8b3;		2		1	15	15	2			2	
H1365	002	0	1	04	01	H1365_002_0	4	9	9	10		14c;	1	350.00	2			2			2	
H1365	003	0	1	04	01	H1365_003_0	4	1	1	11	3-1;3-2;3-3;5;7b;7c;7d;7e;7f;7g;7h;7i;8b1;8b2;9a;9b;9c;9d;11a;11b;14a;16b;17a;17b;18a;	14b;17a;	2		1	30	30	2			2	
H1365	003	0	1	04	01	H1365_003_0	4	10	10	10		13a;	1	200.00	2			2			2	
H1365	003	0	1	04	01	H1365_003_0	4	2	2	01	6;11c;12;15;		2		1	20	20	2			2	
H1365	003	0	1	04	01	H1365_003_0	4	3	3	01	8a1;		2		1	0	15	2			2	
H1365	003	0	1	04	01	H1365_003_0	4	4	4	01	8a2;		2		1	0	20	2			2	
H1365	003	0	1	04	01	H1365_003_0	4	5	5	01	14d;14e;		2		2			2			2	
H1365	003	0	1	04	01	H1365_003_0	4	6	6	01	10a;		2		2			1	250.00	250.00	2	
H1365	003	0	1	04	01	H1365_003_0	4	7	7	01	7a;		2		2			1	25.00	25.00	2	
H1365	003	0	1	04	01	H1365_003_0	4	8	8	01	8b3;		2		1	15	15	2			2	
H1365	003	0	1	04	01	H1365_003_0	4	9	9	10		14c;	1	350.00	2			2			2	
H1365	802	0	1	04	01	H1365_802_0	2	1	1	01	6;14a;		2		2			2			2	
H1365	802	0	1	04	01	H1365_802_0	2	2	2	01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1365	803	0	1	04	01	H1365_803_0	2	1	1	01	6;14a;		2		2			2			2	
H1365	803	0	1	04	01	H1365_803_0	2	2	2	01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1468	007	0	1	01	01	H1468_007_0	2	1														
H1468	013	0	1	01	01	H1468_013_0	2	1														
H1468	014	0	1	01	01	H1468_014_0	2	1														
H1468	015	0	1	01	01	H1468_015_0	2	1														
H1468	016	0	1	01	01	H1468_016_0	2	1														
H1468	017	0	1	01	01	H1468_017_0	3	1														
H1537	004	0	1	04	01	H1537_004_0	6	1	Group 1	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8b1;8b2;8b3;9a;9b;11b;11c;14d;14e;15;16b;17a;17b;18a;	7f;14b;17a;18a;	2		1	40	40	2			2	
H1537	004	0	1	04	01	H1537_004_0	6	2	Group 2	11	9d;	9d;14c;18b;	2		2			1	0.00	0.00	2	
H1537	004	0	1	04	01	H1537_004_0	6	3	Group 3	01	6;11a;		2		1	50	50	2			2	
H1537	004	0	1	04	01	H1537_004_0	6	4	Group 4	01	12;		2		1	20	20	2			2	
H1537	004	0	1	04	01	H1537_004_0	6	5	Group 5	01	10a;		2		2			1	250.00	250.00	2	
H1537	004	0	1	04	01	H1537_004_0	6	6	Group 6	01	14a;		2		1	0	40	2			2	
H1537	004	0	1	04	01	H1537_004_0	6	7	Group 7	01	8a2;		2		2			1	10.00	10.00	2	
H1537	004	0	1	04	01	H1537_004_0	6	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H1537	004	0	1	04	01	H1537_004_0	6	9	Group 9	01	5;		2		2			1	75.00	75.00	2	
H1537	801	0	1	04	01	H1537_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
H1537	801	0	1	04	01	H1537_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1537	802	0	1	04	01	H1537_802_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1537	802	0	1	04	01	H1537_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1537	803	0	1	04	01	H1537_803_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1537	803	0	1	04	01	H1537_803_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1537	804	0	2	04	01	H1537_804_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1537	804	0	2	04	01	H1537_804_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1537	805	0	2	04	01	H1537_805_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1537	805	0	2	04	01	H1537_805_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1537	806	0	2	04	01	H1537_806_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1537	806	0	2	04	01	H1537_806_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1537	807	0	1	04	01	H1537_807_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1537	807	0	1	04	01	H1537_807_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1537	808	0	1	04	01	H1537_808_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1537	808	0	1	04	01	H1537_808_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1537	809	0	1	04	01	H1537_809_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1537	809	0	1	04	01	H1537_809_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1537	816	0	1	04	01	H1537_816_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1537	816	0	1	04	01	H1537_816_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1537	817	0	1	04	01	H1537_817_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1537	817	0	1	04	01	H1537_817_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1537	823	0	1	04	01	H1537_823_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1537	823	0	1	04	01	H1537_823_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1537	824	0	1	04	01	H1537_824_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1537	824	0	1	04	01	H1537_824_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1537	825	0	1	04	01	H1537_825_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1537	825	0	1	04	01	H1537_825_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1537	826	0	1	04	01	H1537_826_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1537	826	0	1	04	01	H1537_826_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1537	827	0	2	04	01	H1537_827_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1537	827	0	2	04	01	H1537_827_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1537	828	0	2	04	01	H1537_828_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1537	828	0	2	04	01	H1537_828_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1537	829	0	2	04	01	H1537_829_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1537	829	0	2	04	01	H1537_829_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1537	830	0	1	04	01	H1537_830_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1537	830	0	1	04	01	H1537_830_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1537	831	0	1	04	01	H1537_831_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1537	831	0	1	04	01	H1537_831_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1537	832	0	1	04	01	H1537_832_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1537	832	0	1	04	01	H1537_832_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1537	833	0	1	04	01	H1537_833_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1537	833	0	1	04	01	H1537_833_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1537	834	0	1	04	01	H1537_834_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1537	834	0	1	04	01	H1537_834_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1607	012	0	1	04	01	H1607_012_0	5	1	$0	11	9d;16b;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H1607	012	0	1	04	01	H1607_012_0	5	2	20%	11	8b2;12;15;	16a;18a;	2		1	20	20	2			2	
H1607	012	0	1	04	01	H1607_012_0	5	3	Ambulance	01	10a;		2		1	20	20	1	295.00	295.00	2	
H1607	012	0	1	04	01	H1607_012_0	5	4	Diag/Rad	01	8a1;8a2;8b1;8b3;		2		1	30	30	2			2	
H1607	012	0	1	04	01	H1607_012_0	5	5	PCP	01	7a;7g;		2		2			1	40.00	40.00	2	
H1607	012	0	1	04	01	H1607_012_0	5	6	SPEC	11	7b;7c;7d;7e;7f;7h;7i;	7f;14b;	2		2			1	60.00	60.00	2	
H1607	012	0	1	04	01	H1607_012_0	5	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;17a;18a;		2		1	40	40	2			2	
H1607	012	0	1	04	01	H1607_012_0	5	8	$0	10		14c;	1	95.00	2			1	0.00	0.00	2	
H1607	012	0	1	04	01	H1607_012_0	5	9	50%	10		18b;	2		1	50	50	2			2	
H1607	804	0	1	04	01	H1607_804_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1607	804	0	1	04	01	H1607_804_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1607	805	0	1	04	01	H1607_805_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1607	805	0	1	04	01	H1607_805_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1607	806	0	1	04	01	H1607_806_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1607	806	0	1	04	01	H1607_806_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1608	001	0	1	04	01	H1608_001_0	6	1	40% Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	9d;14b;17a;	2		1	40	40	2			2	
H1608	001	0	1	04	01	H1608_001_0	6	2	Ambulance	01	10a;		2		2			1	350.00	350.00	2	
H1608	001	0	1	04	01	H1608_001_0	6	3	0%-40% Tier	10		14c;	2		1	0	40	2			2	
H1608	001	0	1	04	01	H1608_001_0	6	4	0%-40% Tier (14a)	01	14a;		2		1	0	40	2			2	
H1608	001	0	1	04	01	H1608_001_0	6	5	0% - 20% Tier	01	11c;		2		1	0	20	2			2	
H1608	001	0	1	04	01	H1608_001_0	6	6	OTC $25 each month	10		13b;	1	25.00	2			1	0.00	0.00	2	
H1608	001	0	1	04	01	H1608_001_0	6	7	0%	11	14d;	16a;	2		1	0	0	2			2	
H1608	004	0	1	04	01	H1608_004_0	3	1	45% Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;12;14e;15;16b;17a;17b;18a;	9d;14b;17a;	2		1	45	45	2			2	
H1608	004	0	1	04	01	H1608_004_0	3	2	Ambulance	01	10a;		2		2			1	305.00	305.00	2	
H1608	004	0	1	04	01	H1608_004_0	3	3	0%-45% Tier	10		14c;	2		1	0	45	2			2	
H1608	004	0	1	04	01	H1608_004_0	3	4	0%-45% Tier	01	14a;		2		1	0	45	2			2	
H1608	004	0	1	04	01	H1608_004_0	3	5	40% Tier	01	11a;11b;		2		1	40	40	2			2	
H1608	004	0	1	04	01	H1608_004_0	3	6	$0 Tier - Dental and Eyewear	10		16a;17b;	2		2			1	0.00	0.00	2	
H1608	004	0	1	04	01	H1608_004_0	3	7	0% - 20% Tier	01	11c;		2		1	0	20	2			2	
H1608	004	0	1	04	01	H1608_004_0	3	8	OTC $20 each month	10		13b;	1	20.00	2			1	0.00	0.00	2	
H1608	004	0	1	04	01	H1608_004_0	3	9	0%	01	14d;		2		1	0	0	2			2	
H1608	007	0	1	04	01	H1608_007_0	3	1	45% Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;12;14e;15;16b;17a;17b;18a;	9d;14b;17a;	2		1	45	45	2			2	
H1608	007	0	1	04	01	H1608_007_0	3	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H1608	007	0	1	04	01	H1608_007_0	3	3	0%-45% Tier	10		14c;	2		1	0	45	2			2	
H1608	007	0	1	04	01	H1608_007_0	3	4	0%-45% Tier	01	14a;		2		1	0	45	2			2	
H1608	007	0	1	04	01	H1608_007_0	3	5	20% 11a and 11b	01	11a;11b;		2		1	20	20	2			2	
H1608	007	0	1	04	01	H1608_007_0	3	6	$0 Tier - Dental and Eyewear	10		16a;16b;17b;	2		2			1	0.00	0.00	2	
H1608	007	0	1	04	01	H1608_007_0	3	7	0%	01	14d;		2		1	0	0	2			2	
H1608	007	0	1	04	01	H1608_007_0	3	8	0% - 20% Tier	01	11c;		2		1	0	20	2			2	
H1608	007	0	1	04	01	H1608_007_0	3	9	OTC $20 each month	10		13b;	1	20.00	2			1	0.00	0.00	2	
H1608	008	0	1	04	01	H1608_008_0	4	1	45% Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;12;14e;15;16b;17a;17b;18a;	9d;14b;17a;	2		1	45	45	2			2	
H1608	008	0	1	04	01	H1608_008_0	4	10	0%	01	14d;		2		1	0	0	2			2	
H1608	008	0	1	04	01	H1608_008_0	4	11	GDS - OON Comp	10		16b;	2		1	50	50	2			1	100.00
H1608	008	0	1	04	01	H1608_008_0	4	2	Ambulance	01	10a;		2		2			1	350.00	350.00	2	
H1608	008	0	1	04	01	H1608_008_0	4	3	0%-45% Tier (14c)	10		14c;	2		1	0	45	2			2	
H1608	008	0	1	04	01	H1608_008_0	4	4	0%-45% Tier	01	14a;		2		1	0	45	2			2	
H1608	008	0	1	04	01	H1608_008_0	4	5	20% for 11a and 11b	01	11a;11b;		2		1	20	20	2			2	
H1608	008	0	1	04	01	H1608_008_0	4	6	30% Tier - GDS Preventive Dental	10		16a;	2		1	30	30	2			1	100.00
H1608	008	0	1	04	01	H1608_008_0	4	7	$0 Tier	10		17b;	2		2			1	0.00	0.00	2	
H1608	008	0	1	04	01	H1608_008_0	4	8	0% - 20% Tier	01	11c;		2		1	0	20	2			2	
H1608	008	0	1	04	01	H1608_008_0	4	9	OTC $20 monthly	10		13b;	1	20.00	2			1	0.00	0.00	2	
H1608	012	0	1	04	01	H1608_012_0	4	1	40% Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	9d;14b;17a;	2		1	40	40	2			2	
H1608	012	0	1	04	01	H1608_012_0	4	2	Ambulance	01	10a;		2		2			1	285.00	285.00	2	
H1608	012	0	1	04	01	H1608_012_0	4	3	0%-40% Tier	11	14a;	14c;	2		1	0	40	2			2	
H1608	012	0	1	04	01	H1608_012_0	4	4	30% Tier - GDS Preventive Dental	10		16a;	2		1	30	30	2			1	75.00
H1608	012	0	1	04	01	H1608_012_0	4	5	$0 Tier	10		17b;	2		2			1	0.00	0.00	2	
H1608	012	0	1	04	01	H1608_012_0	4	6	0% - 20% Tier	01	11c;		2		1	0	20	2			2	
H1608	012	0	1	04	01	H1608_012_0	4	7	OTC $20 monthly	10		13b;	1	20.00	2			1	0.00	0.00	2	
H1608	012	0	1	04	01	H1608_012_0	4	8	0%	01	14d;		2		1	0	0	2			2	
H1608	013	0	1	04	01	H1608_013_0	5	1	OON Standard Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		1	30	30	2			2	
H1608	013	0	1	04	01	H1608_013_0	5	2	OON Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H1608	013	0	1	04	01	H1608_013_0	5	3	OON Supplemental Benefits 14c	10		14c;	2		1	0	30	2			2	
H1608	013	0	1	04	01	H1608_013_0	5	4	Dental, Eye, Hearing	10		16a;17b;18b;	2		2			1	0.00	0.00	2	
H1608	013	0	1	04	01	H1608_013_0	5	5	OON 14a Preventive Benefits	01	14a;		2		1	0	30	2			2	
H1608	013	0	1	04	01	H1608_013_0	5	6	14d Kidney Disease Education	01	14d;		2		1	0	0	2			2	
H1608	013	0	1	04	01	H1608_013_0	5	7	11C Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H1608	016	0	1	04	01	H1608_016_0	6	1	OON 45% Coinsurance	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;12;14d;14e;15;16b;17a;17b;18a;	9d;10b;13c;14b;17a;	2		1	45	45	2			2	
H1608	016	0	1	04	01	H1608_016_0	6	2	OON No cost share	01	6;		2		1	0	0	2			2	
H1608	016	0	1	04	01	H1608_016_0	6	3	OON 14c Supplemental Benefits	11	14a;	14c;	2		1	0	45	2			2	
H1608	016	0	1	04	01	H1608_016_0	6	4	OON Ambulance	01	10a;		2		2			1	310.00	310.00	2	
H1608	016	0	1	04	01	H1608_016_0	6	5	20% Coinsurance	01	11a;11b;		2		1	20	20	2			2	
H1608	016	0	1	04	01	H1608_016_0	6	6	11c Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H1608	017	0	1	04	01	H1608_017_0	5	1	OON 45% Coinsurance	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;12;14d;14e;15;16b;17a;17b;18a;	9d;10b;13c;14b;17a;	2		1	45	45	2			2	
H1608	017	0	1	04	01	H1608_017_0	5	2	OON No cost share	01	6;		2		1	0	0	2			2	
H1608	017	0	1	04	01	H1608_017_0	5	3	OON 14c Supplemental Benefits	11	14a;	14c;	2		1	0	45	2			2	
H1608	017	0	1	04	01	H1608_017_0	5	4	OON Ambulance	01	10a;		2		2			1	250.00	250.00	2	
H1608	017	0	1	04	01	H1608_017_0	5	5	20% Coinsurance	01	11a;11b;		2		1	20	20	2			2	
H1608	017	0	1	04	01	H1608_017_0	5	6	11c Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H1608	018	0	1	04	01	H1608_018_0	4	1	OON Ambulance	01	10a;		2		2			1	350.00	350.00	2	
H1608	018	0	1	04	01	H1608_018_0	4	2	OON No Cost Share	11	6;	16a;	2		1	0	0	2			2	
H1608	018	0	1	04	01	H1608_018_0	4	3	OON 45% Coinsurance	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;12;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;17b;	2		1	45	45	2			2	
H1608	018	0	1	04	01	H1608_018_0	4	4	OON 14c Supplemental Benefits	11	14a;	14c;	2		1	0	45	2			2	
H1608	018	0	1	04	01	H1608_018_0	4	5	OON 20% Coinsurance	01	11a;11b;		2		1	20	20	2			2	
H1608	018	0	1	04	01	H1608_018_0	4	6	11c Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H1608	021	0	1	04	01	H1608_021_0	5	1	OON Ambulance	01	10a;		2		2			1	330.00	330.00	2	
H1608	021	0	1	04	01	H1608_021_0	5	2	OON No cost share	11	6;	16a;	2		1	0	0	2			2	
H1608	021	0	1	04	01	H1608_021_0	5	3	OON 50% Coinsurance	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;12;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;17b;	2		1	50	50	2			2	
H1608	021	0	1	04	01	H1608_021_0	5	4	OON 14c Supplemental Benefits	11	14a;	14c;	2		1	0	50	2			2	
H1608	021	0	1	04	01	H1608_021_0	5	5	OON 20% Coinsurance	01	11a;11b;		2		1	20	20	2			2	
H1608	021	0	1	04	01	H1608_021_0	5	6	11c Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H1608	023	0	1	04	01	H1608_023_0	4	1	OON Ambulance	01	10a;		2		2			1	280.00	280.00	2	
H1608	023	0	1	04	01	H1608_023_0	4	2	OON No Cost Share	11	6;	16a;	2		1	0	0	2			2	
H1608	023	0	1	04	01	H1608_023_0	4	3	OON 45% Coinsurance	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;12;14d;14e;15;16b;17a;17b;18a;	9d;10b;13c;14b;17a;17b;	2		1	45	45	2			2	
H1608	023	0	1	04	01	H1608_023_0	4	4	OON 14c Supplemental Benefits	11	14a;	14c;	2		1	0	45	2			2	
H1608	023	0	1	04	01	H1608_023_0	4	5	OON 20% Coinsurance	01	11a;11b;		2		1	20	20	2			2	
H1608	023	0	1	04	01	H1608_023_0	4	6	11c Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H1608	024	0	1	04	01	H1608_024_0	4	1	OON Ambulance	01	10a;		2		2			1	270.00	270.00	2	
H1608	024	0	1	04	01	H1608_024_0	4	2	OON No cost share	11	6;	16a;	2		1	0	0	2			2	
H1608	024	0	1	04	01	H1608_024_0	4	3	OON 45% Coinsurance	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;12;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;17b;	2		1	45	45	2			2	
H1608	024	0	1	04	01	H1608_024_0	4	4	OON 14c Supplemental Benefits	11	14a;	14c;	2		1	0	45	2			2	
H1608	024	0	1	04	01	H1608_024_0	4	5	OON 20% Coinsurance	01	11a;11b;		2		1	20	20	2			2	
H1608	024	0	1	04	01	H1608_024_0	4	6	11 c Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H1608	026	0	1	04	01	H1608_026_0	5	1	20% Coinsurance OON	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		1	20	20	2			2	
H1608	026	0	1	04	01	H1608_026_0	5	2	30% Coinsurance OON	01	11a;11b;12;		2		1	30	30	2			2	
H1608	026	0	1	04	01	H1608_026_0	5	3	45% Coinsurance OON	01	5;7e;7h;9c;		2		1	45	45	2			2	
H1608	026	0	1	04	01	H1608_026_0	5	4	$0 Copayment OON	11	6;14d;	14c;17b;	2		2			1	0.00	0.00	2	
H1608	026	0	1	04	01	H1608_026_0	5	5	0-20% OON	01	11c;14a;		2		1	0	20	2			2	
H1608	026	0	1	04	01	H1608_026_0	5	6	$300 Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H1608	026	0	1	04	01	H1608_026_0	5	7	50% Comprehensive Dental (Non Medicare)	10		16b;	2		1	50	50	2			1	100.00
H1608	026	0	1	04	01	H1608_026_0	5	8	30% Preventive Dental (Non Medicare)	10		16a;	2		1	30	30	2			1	100.00
H1608	027	0	1	04	01	H1608_027_0	4	1	20% Coinsurance OON	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		1	20	20	2			2	
H1608	027	0	1	04	01	H1608_027_0	4	10	Acupuncture	10		13a;	2		2			1	10.00	10.00	2	
H1608	027	0	1	04	01	H1608_027_0	4	2	30% Coinsurance OON	01	11a;11b;12;		2		1	30	30	2			2	
H1608	027	0	1	04	01	H1608_027_0	4	3	45% Coinsurance OON	01	5;7e;7h;9c;		2		1	45	45	2			2	
H1608	027	0	1	04	01	H1608_027_0	4	4	$0 Copayment OON	11	6;14d;	14c;17b;	2		2			1	0.00	0.00	2	
H1608	027	0	1	04	01	H1608_027_0	4	5	0-20% OON	01	11c;14a;		2		1	0	20	2			2	
H1608	027	0	1	04	01	H1608_027_0	4	6	$200 Ambulance	01	10a;		2		2			1	200.00	200.00	2	
H1608	027	0	1	04	01	H1608_027_0	4	7	50% Comprehensive Dental (Non Medicare)	10		16b;	2		1	50	50	2			1	100.00
H1608	027	0	1	04	01	H1608_027_0	4	8	30% Preventive Dental (Non Medicare)	10		16a;	2		1	30	30	2			1	100.00
H1608	027	0	1	04	01	H1608_027_0	4	9	OTC	10		13b;	1	25.00	2			2			2	
H1608	028	0	1	04	01	H1608_028_0	5	1	Coins.40%	11	5;6;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;12;15;17b;	9d;	2		1	40	40	2			2	
H1608	028	0	1	04	01	H1608_028_0	5	10	0%-40%	01	14a;		2		1	0	40	2			2	
H1608	028	0	1	04	01	H1608_028_0	5	11	25%	01	11a;11b;		2		1	25	25	2			2	
H1608	028	0	1	04	01	H1608_028_0	5	2	Zero costshare	11	14d;14e;	14b;14c;17a;	2		2			1	0.00	0.00	2	
H1608	028	0	1	04	01	H1608_028_0	5	3	0%-20% Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H1608	028	0	1	04	01	H1608_028_0	5	4	$49 Costshare	01	7f;		2		2			1	49.00	49.00	2	
H1608	028	0	1	04	01	H1608_028_0	5	5	$55 Costshare	11	3-1;3-2;3-3;7b;7c;7d;7e;7g;7h;7i;16b;17a;18a;	18a;	2		2			1	55.00	55.00	2	
H1608	028	0	1	04	01	H1608_028_0	5	6	$100  Allowance	10		17b;	2		2			1	0.00	0.00	2	
H1608	028	0	1	04	01	H1608_028_0	5	7	$250 Allowance	10		16a;	2		2			1	0.00	0.00	2	
H1608	028	0	1	04	01	H1608_028_0	5	8	$40 copay	01	7a;		2		2			1	40.00	40.00	2	
H1608	028	0	1	04	01	H1608_028_0	5	9	$250-Ambulance	01	10a;		2		2			1	250.00	250.00	2	
H1608	029	0	1	04	01	H1608_029_0	6	1	30% Coins Medicare Covered Benefit	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;11a;11b;12;15;16b;17a;17b;18a;	14b;	2		1	30	30	2			2	
H1608	029	0	1	04	01	H1608_029_0	6	2	Diabetic Supplies and Services Group	01	11c;		2		1	0	20	2			2	
H1608	029	0	1	04	01	H1608_029_0	6	3	45% Coinsurance Group	01	5;7e;7h;9c;		2		1	45	45	2			2	
H1608	029	0	1	04	01	H1608_029_0	6	4	0%	01	6;		2		1	0	0	2			2	
H1608	029	0	1	04	01	H1608_029_0	6	5	Ambulance	01	10a;		2		2			1	290.00	290.00	2	
H1608	029	0	1	04	01	H1608_029_0	6	6	$0	11	14d;	14c;	2		2			1	0.00	0.00	2	
H1608	029	0	1	04	01	H1608_029_0	6	7	Preventive	01	14a;		2		1	0	30	2			2	
H1608	029	0	1	04	01	H1608_029_0	6	8	Non-Medicare 30%	10		7f;9d;17a;18a;	2		1	30	30	2			2	
H1608	029	0	1	04	01	H1608_029_0	6	9	OON with separate office visit cost	01	14e;		2		1	30	30	2			2	
H1608	031	0	1	04	01	H1608_031_0	3	1	40% Coinsurance OON	11	3-1;3-2;3-3;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;12;14e;15;16b;17a;17b;18a;	9d;17a;18a;	2		1	40	40	2			2	
H1608	031	0	1	04	01	H1608_031_0	3	2	45% Coinsurance OON	01	5;9c;		2		1	45	45	2			2	
H1608	031	0	1	04	01	H1608_031_0	3	3	$0 Copayment OON	11	6;14d;	14c;	2		2			1	0.00	0.00	2	
H1608	031	0	1	04	01	H1608_031_0	3	4	20% Coinsurance OON	11	7a;7b;7c;7d;7e;7f;7g;7h;7i;	7f;14b;	2		1	20	20	2			2	
H1608	031	0	1	04	01	H1608_031_0	3	5	25% Coinsurance OON	01	11a;11b;		2		1	25	25	2			2	
H1608	031	0	1	04	01	H1608_031_0	3	6	Preventive Services 0-40%	01	14a;		2		1	0	40	2			2	
H1608	031	0	1	04	01	H1608_031_0	3	7	$300 Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H1608	031	0	1	04	01	H1608_031_0	3	8	0-20% OON	01	11c;		2		1	0	20	2			2	
H1608	035	0	1	04	01	H1608_035_0	4	1	OON Standard Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		1	40	40	2			2	
H1608	035	0	1	04	01	H1608_035_0	4	2	OON Ambulance	01	10a;		2		2			1	285.00	285.00	2	
H1608	035	0	1	04	01	H1608_035_0	4	3	OON Supplemental Benefits 14c	10		14c;	2		1	0	40	2			2	
H1608	035	0	1	04	01	H1608_035_0	4	4	OON 14a Preventive Benefits	01	14a;		2		1	0	40	2			2	
H1608	035	0	1	04	01	H1608_035_0	4	5	Dental	10		16a;	2		2			1	0.00	0.00	2	
H1608	035	0	1	04	01	H1608_035_0	4	6	14D- Kidney Disease Education	01	14d;		2		1	0	0	2			2	
H1608	035	0	1	04	01	H1608_035_0	4	7	11c Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H1608	036	0	1	04	01	H1608_036_0	5	1	OON Ambulance	01	10a;		2		2			1	335.00	335.00	2	
H1608	036	0	1	04	01	H1608_036_0	5	2	OON No cost share	11	6;	16a;	2		1	0	0	2			2	
H1608	036	0	1	04	01	H1608_036_0	5	3	OON 45% Coinsurance	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;12;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;17b;	2		1	45	45	2			2	
H1608	036	0	1	04	01	H1608_036_0	5	4	OON 14c Supplemental Benefits	11	14a;	14c;	2		1	0	45	2			2	
H1608	036	0	1	04	01	H1608_036_0	5	5	OON 20% Coinsurance	01	11a;11b;		2		1	20	20	2			2	
H1608	036	0	1	04	01	H1608_036_0	5	6	11c Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H1608	037	0	1	04	01	H1608_037_0	3	1	45% Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;	2		1	45	45	2			2	
H1608	037	0	1	04	01	H1608_037_0	3	2	Ambulance	01	10a;		2		2			1	350.00	350.00	2	
H1608	037	0	1	04	01	H1608_037_0	3	3	20% Tier	01	12;		2		1	20	20	2			2	
H1608	037	0	1	04	01	H1608_037_0	3	4	0%-45% Tier	11	14a;	14c;	2		1	0	45	2			2	
H1608	037	0	1	04	01	H1608_037_0	3	5	0% Tier	11	14d;	16a;16b;17b;	2		1	0	0	2			2	
H1608	037	0	1	04	01	H1608_037_0	3	6	OTC $25 Monthly	10		13b;	1	25.00	2			1	0.00	0.00	2	
H1608	037	0	1	04	01	H1608_037_0	3	7	0%-20%	01	11c;		2		1	0	20	2			2	
H1608	038	0	1	04	01	H1608_038_0	4	1	50% Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H1608	038	0	1	04	01	H1608_038_0	4	2	Ambulance	01	10a;		2		2			1	350.00	350.00	2	
H1608	038	0	1	04	01	H1608_038_0	4	3	20% Tier	01	12;		2		1	20	20	2			2	
H1608	038	0	1	04	01	H1608_038_0	4	4	0%-50% Tier	11	14a;	14c;	2		1	0	50	2			2	
H1608	038	0	1	04	01	H1608_038_0	4	5	0% Tier	11	14d;	16a;16b;17b;18b;	2		1	0	0	2			2	
H1608	038	0	1	04	01	H1608_038_0	4	6	OTC $20 Monthly	10		13b;	1	20.00	2			1	0.00	0.00	2	
H1608	038	0	1	04	01	H1608_038_0	4	7	0%-20%	01	11c;		2		1	0	20	2			2	
H1608	801	0	1	04	01	H1608_801_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1608	801	0	1	04	01	H1608_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1608	802	0	1	04	01	H1608_802_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1608	802	0	1	04	01	H1608_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1608	814	0	1	04	01	H1608_814_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1608	814	0	1	04	01	H1608_814_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1608	815	0	1	04	01	H1608_815_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1608	815	0	1	04	01	H1608_815_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1608	816	0	1	04	01	H1608_816_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1608	816	0	1	04	01	H1608_816_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1608	817	0	1	04	01	H1608_817_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1608	817	0	1	04	01	H1608_817_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1608	818	0	1	04	01	H1608_818_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1608	818	0	1	04	01	H1608_818_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1608	819	0	1	04	01	H1608_819_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1608	819	0	1	04	01	H1608_819_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1608	822	0	1	04	01	H1608_822_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1608	822	0	1	04	01	H1608_822_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1608	823	0	1	04	01	H1608_823_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1608	823	0	1	04	01	H1608_823_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1608	824	0	1	04	01	H1608_824_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1608	824	0	1	04	01	H1608_824_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1659	001	0	1	04	01	H1659_001_0	5	1	Cardiac/Pulmonary Rehab	01	3-1;3-2;3-3;		2		1	40	40	2			2	
H1659	001	0	1	04	01	H1659_001_0	5	10	Part B Rx	01	15;		2		1	40	40	2			2	
H1659	001	0	1	04	01	H1659_001_0	5	11	Dental Comp (Medicare cov)	01	16b;		2		1	40	40	2			2	
H1659	001	0	1	04	01	H1659_001_0	5	12	Eye Exams, Hearing	11	17a;17b;18a;	17a;	2		1	40	40	2			2	
H1659	001	0	1	04	01	H1659_001_0	5	13	Outpatient	01	9a;9b;9c;9d;		2		1	40	40	2			2	
H1659	001	0	1	04	01	H1659_001_0	5	14	Xrays/Diag Proc/Labs/Rad	01	8a1;8a2;8b1;8b2;8b3;		2		1	40	40	2			2	
H1659	001	0	1	04	01	H1659_001_0	5	15	Eligible Supplemental Benefits	10		14c;	2		2			2			2	
H1659	001	0	1	04	01	H1659_001_0	5	2	PCP, Chiro, OT, PT, SLP, MH, Psychiatric	01	7a;7b;7c;7d;7e;7f;7g;7h;7i;		2		1	40	40	2			2	
H1659	001	0	1	04	01	H1659_001_0	5	3	Partial Hospitalization	01	5;		2		1	40	40	2			2	
H1659	001	0	1	04	01	H1659_001_0	5	4	Home Health	01	6;		2		1	40	40	2			2	
H1659	001	0	1	04	01	H1659_001_0	5	5	Eyewear	10		17b;	2		2			2			2	
H1659	001	0	1	04	01	H1659_001_0	5	6	Ambulance	01	10a;		2		1	40	40	2			2	
H1659	001	0	1	04	01	H1659_001_0	5	7	DME/Prosthetics/Diabetic	01	11a;11b;11c;		2		1	40	40	2			2	
H1659	001	0	1	04	01	H1659_001_0	5	8	ESRD	01	12;		2		1	40	40	2			2	
H1659	001	0	1	04	01	H1659_001_0	5	9	Preventive/Kidney Ed/Diabetes Ed	01	14a;14d;14e;		2		1	40	40	2			2	
H1659	002	0	1	04	01	H1659_002_0	5	1	Cardiac/Pulmonary Rehab	01	3-1;3-2;3-3;		2		1	40	40	2			2	
H1659	002	0	1	04	01	H1659_002_0	5	10	Dental Comp (Medicare Cov)	01	16b;		2		1	40	40	2			2	
H1659	002	0	1	04	01	H1659_002_0	5	11	Eye Exams, Hearing	11	17a;17b;18a;	17a;	2		1	40	40	2			2	
H1659	002	0	1	04	01	H1659_002_0	5	12	Outpatient	01	9a;9b;9c;9d;		2		1	40	40	2			2	
H1659	002	0	1	04	01	H1659_002_0	5	13	Xrays/Diag Proc/Labs/Rad	01	8a1;8a2;8b1;8b2;8b3;		2		1	40	40	2			2	
H1659	002	0	1	04	01	H1659_002_0	5	14	Eligible Supplemental Benefits	10		14c;	2		2			2			2	
H1659	002	0	1	04	01	H1659_002_0	5	2	PCP, Chiro, OT, PT, SLP, MH, Psychiatric	01	7a;7b;7c;7d;7e;7f;7g;7h;7i;		2		1	40	40	2			2	
H1659	002	0	1	04	01	H1659_002_0	5	3	Partial Hospitalization	01	5;		2		1	40	40	2			2	
H1659	002	0	1	04	01	H1659_002_0	5	4	Home Health	01	6;		2		1	40	40	2			2	
H1659	002	0	1	04	01	H1659_002_0	5	5	Ambulance	01	10a;		2		1	40	40	2			2	
H1659	002	0	1	04	01	H1659_002_0	5	6	DME/Prosthetics/Diabetic	01	11a;11b;11c;		2		1	40	40	2			2	
H1659	002	0	1	04	01	H1659_002_0	5	7	ESRD	01	12;		2		1	40	40	2			2	
H1659	002	0	1	04	01	H1659_002_0	5	8	Preventive/Kidney Ed/Diabetes Ed	01	14a;14d;14e;		2		1	40	40	2			2	
H1659	002	0	1	04	01	H1659_002_0	5	9	Part B Rx	01	15;		2		1	40	40	2			2	
H1659	003	0	1	04	01	H1659_003_0	5	1	Cardiac/Pulmonary Rehab	01	3-1;3-2;3-3;		2		1	40	40	2			2	
H1659	003	0	1	04	01	H1659_003_0	5	10	Dental Comp (Medicare Cov)	01	16b;		2		1	40	40	2			2	
H1659	003	0	1	04	01	H1659_003_0	5	11	Eye Exams, Hearing	11	17a;17b;18a;	17a;	2		1	40	40	2			2	
H1659	003	0	1	04	01	H1659_003_0	5	12	Outpatient	01	9a;9b;9c;9d;		2		1	40	40	2			2	
H1659	003	0	1	04	01	H1659_003_0	5	13	Xrays/Diag Proc/Labs/Rad	01	8a1;8a2;8b1;8b2;8b3;		2		1	40	40	2			2	
H1659	003	0	1	04	01	H1659_003_0	5	14	Eligible Supplemental Benefits	10		14c;	2		2			2			2	
H1659	003	0	1	04	01	H1659_003_0	5	2	PCP, Chiro, OT, PT, SLP, MH, Psychiatric	01	7a;7b;7c;7d;7e;7f;7g;7h;7i;		2		1	40	40	2			2	
H1659	003	0	1	04	01	H1659_003_0	5	3	Partial Hospitalization	01	5;		2		1	40	40	2			2	
H1659	003	0	1	04	01	H1659_003_0	5	4	Home Health	01	6;		2		1	40	40	2			2	
H1659	003	0	1	04	01	H1659_003_0	5	5	Ambulance	01	10a;		2		1	40	40	2			2	
H1659	003	0	1	04	01	H1659_003_0	5	6	DME/Prosthetics/Diabetic	01	11a;11b;11c;		2		1	40	40	2			2	
H1659	003	0	1	04	01	H1659_003_0	5	7	ESRD	01	12;		2		1	40	40	2			2	
H1659	003	0	1	04	01	H1659_003_0	5	8	Preventive/Kidney Ed/Diabetes Ed	01	14a;14d;14e;		2		1	40	40	2			2	
H1659	003	0	1	04	01	H1659_003_0	5	9	Part B Rx	01	15;		2		1	40	40	2			2	
H1666	001	0	1	04	01	H1666_001_0	10	1	50% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	14b;	2		1	50	50	2			2	
H1666	001	0	1	04	01	H1666_001_0	10	2	$300 Copay	01	10a;		2		2			1	300.00	300.00	2	
H1666	001	0	1	04	01	H1666_001_0	10	3	20% Coinsurance	01	12;		2		1	20	20	2			2	
H1666	001	0	1	04	01	H1666_001_0	10	4	0 Copay/ 0 Coinsurance	10		14c;	2		2			2			2	
H1666	001	0	1	04	01	H1666_001_0	10	5	$5 copay	10		16a;	2		2			1	5.00	5.00	2	
H1666	001	0	1	04	01	H1666_001_0	10	6	30%	01	11a;		2		1	30	30	2			2	
H1666	001	0	1	04	01	H1666_001_0	10	7	Eye Exams	10		17a;	2		2			2			2	
H1666	001	0	1	04	01	H1666_001_0	10	8	Eyewear	10		17b;	2		2			2			2	
H1666	002	0	1	04	01	H1666_002_0	7	1	50% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	14b;	2		1	50	50	2			2	
H1666	002	0	1	04	01	H1666_002_0	7	2	$300 Copay	01	10a;		2		2			1	300.00	300.00	2	
H1666	002	0	1	04	01	H1666_002_0	7	3	20% Coinsurance	01	12;		2		1	20	20	2			2	
H1666	002	0	1	04	01	H1666_002_0	7	4	0 Copay/ 0 Coinsurance	10		14c;	2		2			2			2	
H1666	002	0	1	04	01	H1666_002_0	7	5	$5 copay	10		16a;	2		2			1	5.00	5.00	2	
H1666	002	0	1	04	01	H1666_002_0	7	6	30%	01	11a;		2		1	30	30	2			2	
H1666	002	0	1	04	01	H1666_002_0	7	7	Eye Exams	10		17a;	2		2			2			2	
H1666	002	0	1	04	01	H1666_002_0	7	8	Eyewear	10		17b;	2		2			2			2	
H1666	003	0	1	04	01	H1666_003_0	7	1	50% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	14b;	2		1	50	50	2			2	
H1666	003	0	1	04	01	H1666_003_0	7	2	$300 Copay	01	10a;		2		2			1	300.00	300.00	2	
H1666	003	0	1	04	01	H1666_003_0	7	3	20% Coinsurance	01	12;		2		1	20	20	2			2	
H1666	003	0	1	04	01	H1666_003_0	7	4	0 Copay/ 0 Coinsurance	10		14c;	2		2			2			2	
H1666	003	0	1	04	01	H1666_003_0	7	5	$5 copay	10		16a;	2		2			1	5.00	5.00	2	
H1666	003	0	1	04	01	H1666_003_0	7	6	30%	01	11a;		2		1	30	30	2			2	
H1666	003	0	1	04	01	H1666_003_0	7	7	Eye Exams	10		17a;	2		2			2			2	
H1666	003	0	1	04	01	H1666_003_0	7	8	Eyewear	10		17b;	2		2			2			2	
H1666	004	0	1	04	01	H1666_004_0	7	1	50% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	14b;	2		1	50	50	2			2	
H1666	004	0	1	04	01	H1666_004_0	7	2	$300  Copay	01	10a;		2		2			1	300.00	300.00	2	
H1666	004	0	1	04	01	H1666_004_0	7	3	20% Coinsurance	01	12;		2		1	20	20	2			2	
H1666	004	0	1	04	01	H1666_004_0	7	4	0 Copay/ 0 Coinsurance	10		14c;	2		2			2			2	
H1666	004	0	1	04	01	H1666_004_0	7	5	30	01	11a;		2		1	30	30	2			2	
H1666	004	0	1	04	01	H1666_004_0	7	6	Eye Exam	10		17a;	2		2			2			2	
H1666	004	0	1	04	01	H1666_004_0	7	7	Eyewear	10		17b;	2		2			2			2	
H1666	005	0	1	04	01	H1666_005_0	7	1	50% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	14b;	2		1	50	50	2			2	
H1666	005	0	1	04	01	H1666_005_0	7	2	$300  Copay	01	10a;		2		2			1	300.00	300.00	2	
H1666	005	0	1	04	01	H1666_005_0	7	3	20% Coinsurance	01	12;		2		1	20	20	2			2	
H1666	005	0	1	04	01	H1666_005_0	7	4	0 Copay/ 0 Coinsurance	10		14c;	2		2			2			2	
H1666	005	0	1	04	01	H1666_005_0	7	5	30	01	11a;		2		1	30	30	2			2	
H1666	005	0	1	04	01	H1666_005_0	7	6	Eye Exam	10		17a;	2		2			2			2	
H1666	005	0	1	04	01	H1666_005_0	7	7	Eyewear	10		17b;	2		2			2			2	
H1666	006	0	1	04	01	H1666_006_0	7	1	50% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	14b;	2		1	50	50	2			2	
H1666	006	0	1	04	01	H1666_006_0	7	2	$300  Copay	01	10a;		2		2			1	300.00	300.00	2	
H1666	006	0	1	04	01	H1666_006_0	7	3	20% Coinsurance	01	12;		2		1	20	20	2			2	
H1666	006	0	1	04	01	H1666_006_0	7	4	0 Copay/ 0 Coinsurance	10		14c;	2		2			2			2	
H1666	006	0	1	04	01	H1666_006_0	7	5	30	01	11a;		2		1	30	30	2			2	
H1666	006	0	1	04	01	H1666_006_0	7	6	Eye Exam	10		17a;	2		2			2			2	
H1666	006	0	1	04	01	H1666_006_0	7	7	Eyewear	10		17b;	2		2			2			2	
H1666	008	0	1	04	01	H1666_008_0	7	1	50% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	14b;	2		1	50	50	2			2	
H1666	008	0	1	04	01	H1666_008_0	7	2	$300  Copay	01	10a;		2		2			1	300.00	300.00	2	
H1666	008	0	1	04	01	H1666_008_0	7	3	20% Coinsurance	01	12;		2		1	20	20	2			2	
H1666	008	0	1	04	01	H1666_008_0	7	4	0 Copay/ 0 Coinsurance	10		14c;	2		2			2			2	
H1666	008	0	1	04	01	H1666_008_0	7	5	30	01	11a;		2		1	30	30	2			2	
H1666	008	0	1	04	01	H1666_008_0	7	6	Eye Exam	10		17a;	2		2			2			2	
H1666	008	0	1	04	01	H1666_008_0	7	7	Eyewear	10		17b;	2		2			2			2	
H1666	009	0	1	04	01	H1666_009_0	7	1	50% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	14b;	2		1	50	50	2			2	
H1666	009	0	1	04	01	H1666_009_0	7	2	$300 Copay	01	10a;		2		2			1	300.00	300.00	2	
H1666	009	0	1	04	01	H1666_009_0	7	3	20% Coinsurance	01	12;		2		1	20	20	2			2	
H1666	009	0	1	04	01	H1666_009_0	7	4	0 Copay/ 0 Coinsurance	10		14c;	2		2			2			2	
H1666	009	0	1	04	01	H1666_009_0	7	5	$5 copay	10		16a;	2		2			1	5.00	5.00	2	
H1666	009	0	1	04	01	H1666_009_0	7	6	30%	01	11a;		2		1	30	30	2			2	
H1666	009	0	1	04	01	H1666_009_0	7	7	Eye Exams	10		17a;	2		2			2			2	
H1666	009	0	1	04	01	H1666_009_0	7	8	Eyewear	10		17b;	2		2			2			2	
H1666	801	0	1	04	01	H1666_801_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1666	801	0	1	04	01	H1666_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1666	803	0	1	04	01	H1666_803_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1666	803	0	1	04	01	H1666_803_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1666	805	0	1	04	01	H1666_805_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1666	805	0	1	04	01	H1666_805_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1666	807	0	2	04	01	H1666_807_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1666	807	0	2	04	01	H1666_807_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1666	808	0	2	04	01	H1666_808_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1666	808	0	2	04	01	H1666_808_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1846	004	0	1	04	01	H1846_004_0	4	1	#1 Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H1846	004	0	1	04	01	H1846_004_0	4	2	#2 Preventative Ser/Education/Training	11	14a;14d;14e;	14b;14c;	2		2			1	0.00	0.00	2	
H1846	004	0	1	04	01	H1846_004_0	4	3	#3 Outpatient Services/Facilities/Other	11	3-1;3-2;3-3;6;7c;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;15;16b;17b;	9d;	2		1	30	30	2			2	
H1846	004	0	1	04	01	H1846_004_0	4	4	#4  Primary Care Physician	01	7a;		2		2			1	15.00	15.00	2	
H1846	004	0	1	04	01	H1846_004_0	4	5	#5 Other Health Care Professionals	01	7g;		2		2			1	15.00	60.00	2	
H1846	004	0	1	04	01	H1846_004_0	4	6	#6 Specialist	11	5;7d;7e;7f;7h;17a;18a;	17a;18a;	2		2			1	60.00	60.00	2	
H1846	004	0	1	04	01	H1846_004_0	4	7	#7 Chiropractic	01	7b;		2		2			1	40.00	40.00	2	
H1846	801	0	1	04	01	H1846_801_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1846	801	0	1	04	01	H1846_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1846	802	0	1	04	01	H1846_802_0	1	1		01	6;14a;		2		1	0	0	2			2	
H1846	802	0	1	04	01	H1846_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H1951	013	0	1	01	01	H1951_013_0	3	1														
H1951	024	0	1	01	01	H1951_024_0	3	1														
H1951	028	0	1	01	01	H1951_028_0	3	1														
H1951	030	0	1	01	01	H1951_030_0	2	1														
H1951	032	0	1	01	01	H1951_032_0	3	1														
H1951	033	0	1	01	01	H1951_033_0	3	1														
H1951	034	0	1	01	01	H1951_034_0	3	1														
H1951	038	0	1	01	01	H1951_038_0	3	1														
H1951	039	0	1	01	01	H1951_039_0	3	1														
H1951	041	0	1	01	01	H1951_041_0	3	1														
H1951	044	0	1	01	01	H1951_044_0	3	1														
H1951	047	1	1	01	01	H1951_047_1	2	1														
H1951	047	2	1	01	01	H1951_047_2	2	1														
H1951	048	1	1	01	01	H1951_048_1	2	1														
H1951	048	2	1	01	01	H1951_048_2	2	1														
H1951	049	1	1	01	01	H1951_049_1	2	1														
H1951	049	2	1	01	01	H1951_049_2	2	1														
H1951	049	3	1	01	01	H1951_049_3	2	1														
H2001	001	0	1	04	01	H2001_001_0	3	1	Group 1	01	7a;7g;		2		2			1	35.00	50.00	2	
H2001	001	0	1	04	01	H2001_001_0	3	10	Group 10	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
H2001	001	0	1	04	01	H2001_001_0	3	11	Group 11	01	14a;		2		1	0	40	2			2	
H2001	001	0	1	04	01	H2001_001_0	3	12	Group 12	01	6;11a;		2		1	50	50	2			2	
H2001	001	0	1	04	01	H2001_001_0	3	13	Group 13	10		13b;	1	50.00	2			1	0.00	0.00	2	
H2001	001	0	1	04	01	H2001_001_0	3	14	Group 14	01	8b3;		2		2			1	21.00	21.00	2	
H2001	001	0	1	04	01	H2001_001_0	3	15	Group 15	01	8a2;		2		2			1	2.00	2.00	2	
H2001	001	0	1	04	01	H2001_001_0	3	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	50.00	50.00	2	
H2001	001	0	1	04	01	H2001_001_0	3	3	Group 3	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;11b;11c;14d;15;16b;17b;	14b;	2		1	40	40	2			2	
H2001	001	0	1	04	01	H2001_001_0	3	4	Group 4	01	14e;		2		1	40	40	1	50.00	50.00	2	
H2001	001	0	1	04	01	H2001_001_0	3	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
H2001	001	0	1	04	01	H2001_001_0	3	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H2001	001	0	1	04	01	H2001_001_0	3	7	Group 7	01	10a;		2		2			1	250.00	250.00	2	
H2001	001	0	1	04	01	H2001_001_0	3	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H2001	001	0	1	04	01	H2001_001_0	3	9	Group 9	01	12;		2		1	20	20	2			2	
H2001	010	0	1	04	01	H2001_010_0	3	1	Group 1	01	7a;7g;		2		2			1	30.00	45.00	2	
H2001	010	0	1	04	01	H2001_010_0	3	10	Group 10	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
H2001	010	0	1	04	01	H2001_010_0	3	11	Group 11	01	14a;		2		1	0	40	2			2	
H2001	010	0	1	04	01	H2001_010_0	3	12	Group 12	01	6;11a;		2		1	50	50	2			2	
H2001	010	0	1	04	01	H2001_010_0	3	13	Group 13	01	14e;		2		1	40	40	1	45.00	45.00	2	
H2001	010	0	1	04	01	H2001_010_0	3	14	Group 14	01	8b3;		2		2			1	21.00	21.00	2	
H2001	010	0	1	04	01	H2001_010_0	3	15	Group 15	01	8a2;		2		2			1	5.00	5.00	2	
H2001	010	0	1	04	01	H2001_010_0	3	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	45.00	45.00	2	
H2001	010	0	1	04	01	H2001_010_0	3	3	Group 3	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;11b;11c;14d;15;16b;17b;	14b;	2		1	40	40	2			2	
H2001	010	0	1	04	01	H2001_010_0	3	4	Group 4	10		16a;	2		1	75	75	2			2	
H2001	010	0	1	04	01	H2001_010_0	3	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
H2001	010	0	1	04	01	H2001_010_0	3	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H2001	010	0	1	04	01	H2001_010_0	3	7	Group 7	01	10a;		2		2			1	250.00	250.00	2	
H2001	010	0	1	04	01	H2001_010_0	3	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H2001	010	0	1	04	01	H2001_010_0	3	9	Group 9	01	12;		2		1	20	20	2			2	
H2001	017	0	1	04	01	H2001_017_0	3	1	Group 1	01	7a;		2		2			1	20.00	20.00	2	
H2001	017	0	1	04	01	H2001_017_0	3	10	Group 10	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
H2001	017	0	1	04	01	H2001_017_0	3	11	Group 11	01	14a;		2		1	0	30	2			2	
H2001	017	0	1	04	01	H2001_017_0	3	12	Group 12	01	6;		2		1	50	50	2			2	
H2001	017	0	1	04	01	H2001_017_0	3	13	Group 13	01	7g;		2		2			1	20.00	65.00	2	
H2001	017	0	1	04	01	H2001_017_0	3	14	Group 14	01	11a;		2		1	45	45	2			2	
H2001	017	0	1	04	01	H2001_017_0	3	15	Group 15	01	16b;		2		1	40	40	2			2	
H2001	017	0	1	04	01	H2001_017_0	3	2	Group 2	11	7b;7c;7d;7e;7f;7h;7i;9c;17a;18a;	7f;17a;18a;	2		2			1	65.00	65.00	2	
H2001	017	0	1	04	01	H2001_017_0	3	3	Group 3	11	3-1;3-2;3-3;9a;9b;11b;11c;14d;17b;	14b;	2		1	30	30	2			2	
H2001	017	0	1	04	01	H2001_017_0	3	4	Group 4	01	8a1;8a2;8b1;8b2;8b3;		2		1	30	30	1	10.00	21.00	2	
H2001	017	0	1	04	01	H2001_017_0	3	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
H2001	017	0	1	04	01	H2001_017_0	3	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H2001	017	0	1	04	01	H2001_017_0	3	7	Group 7	01	10a;		2		1	30	30	1	250.00	250.00	2	
H2001	017	0	1	04	01	H2001_017_0	3	8	Group 8	01	14e;		2		1	30	30	1	65.00	65.00	2	
H2001	017	0	1	04	01	H2001_017_0	3	9	Group 9	01	12;15;		2		1	20	20	2			2	
H2001	816	0	1	04	01	H2001_816_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2001	816	0	1	04	01	H2001_816_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2001	817	0	1	04	01	H2001_817_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2001	817	0	1	04	01	H2001_817_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2001	818	0	1	04	01	H2001_818_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2001	818	0	1	04	01	H2001_818_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2001	819	0	2	04	01	H2001_819_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2001	819	0	2	04	01	H2001_819_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2001	820	0	2	04	01	H2001_820_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2001	820	0	2	04	01	H2001_820_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2001	821	0	2	04	01	H2001_821_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2001	821	0	2	04	01	H2001_821_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2001	822	0	1	04	01	H2001_822_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2001	822	0	1	04	01	H2001_822_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2001	823	0	1	04	01	H2001_823_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2001	823	0	1	04	01	H2001_823_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2001	824	0	1	04	01	H2001_824_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2001	824	0	1	04	01	H2001_824_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2001	825	0	1	04	01	H2001_825_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2001	825	0	1	04	01	H2001_825_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2001	826	0	1	04	01	H2001_826_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2001	826	0	1	04	01	H2001_826_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2001	827	0	1	04	01	H2001_827_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2001	827	0	1	04	01	H2001_827_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2001	828	0	1	04	01	H2001_828_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2001	828	0	1	04	01	H2001_828_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2001	829	0	1	04	01	H2001_829_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2001	829	0	1	04	01	H2001_829_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2001	830	0	1	04	01	H2001_830_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2001	830	0	1	04	01	H2001_830_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2001	831	0	1	04	01	H2001_831_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2001	831	0	1	04	01	H2001_831_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2001	832	0	2	04	01	H2001_832_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2001	832	0	2	04	01	H2001_832_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2001	833	0	2	04	01	H2001_833_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2001	833	0	2	04	01	H2001_833_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2001	834	0	2	04	01	H2001_834_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2001	834	0	2	04	01	H2001_834_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2001	835	0	1	04	01	H2001_835_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2001	835	0	1	04	01	H2001_835_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2001	836	0	1	04	01	H2001_836_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2001	836	0	1	04	01	H2001_836_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2001	837	0	1	04	01	H2001_837_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2001	837	0	1	04	01	H2001_837_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2001	838	0	1	04	01	H2001_838_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2001	838	0	1	04	01	H2001_838_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2029	001	0	1	04	01	H2029_001_0	4	1		11	9d;17b;	9d;17a;17b;18a;18b;	2		2			1	0.00	0.00	2	
H2029	001	0	1	04	01	H2029_001_0	4	2		01	12;		2		1	20	20	1	0.00	0.00	2	
H2029	001	0	1	04	01	H2029_001_0	4	3		01	10a;		2		1	20	20	1	100.00	100.00	2	
H2029	001	0	1	04	01	H2029_001_0	4	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;15;16b;17a;18a;	13c;14b;14c;16a;16b;	2		1	50	50	2			2	
H2029	001	0	1	04	01	H2029_001_0	4	5		10		13b;	1	50.00	1	50	50	2			2	
H2029	001	0	1	04	01	H2029_001_0	4	6		01	14a;		2		1	50	50	1	0.00	0.00	2	
H2029	801	0	1	04	01	H2029_801_0	3	1		01	6;14a;		2		1	0	0	2			2	
H2029	801	0	1	04	01	H2029_801_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2029	802	0	1	04	01	H2029_802_0	3	1		01	6;14a;		2		1	0	0	2			2	
H2029	802	0	1	04	01	H2029_802_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2029	803	0	1	04	01	H2029_803_0	3	1		01	6;14a;		2		1	0	0	2			2	
H2029	803	0	1	04	01	H2029_803_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2029	805	0	2	04	01	H2029_805_0	3	1		01	6;14a;		2		1	0	0	2			2	
H2029	805	0	2	04	01	H2029_805_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2029	806	0	2	04	01	H2029_806_0	3	1		01	6;14a;		2		1	0	0	2			2	
H2029	806	0	2	04	01	H2029_806_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2029	807	0	2	04	01	H2029_807_0	3	1		01	6;14a;		2		1	0	0	2			2	
H2029	807	0	2	04	01	H2029_807_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2032	001	0	1	04	01	H2032_001_0	9	1	Medicare Covered	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;		2		1	35	35	2			2	
H2032	001	0	1	04	01	H2032_001_0	9	2	Vision	10		17b;	1	125.00	1	35	35	2			2	
H2032	001	0	1	04	01	H2032_001_0	9	3	Hearing	10		18b;	1	1000.00	1	35	35	2			2	
H2032	001	0	1	04	01	H2032_001_0	9	4	Vision and Hearing Exams	10		17a;18a;	2		1	35	35	2			2	
H2032	001	0	1	04	01	H2032_001_0	9	5		10		14c;	2		1	35	35	2			2	
H2032	002	0	1	04	01	H2032_002_0	9	1	Medicare Covered	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;		2		1	35	35	2			2	
H2032	002	0	1	04	01	H2032_002_0	9	2	Vision	10		17b;	1	125.00	1	35	35	2			2	
H2032	002	0	1	04	01	H2032_002_0	9	3	Hearing	10		18b;	1	1000.00	1	35	35	2			2	
H2032	002	0	1	04	01	H2032_002_0	9	4	Vision and Hearing Exams	10		17a;18a;	2		1	35	35	2			2	
H2032	002	0	1	04	01	H2032_002_0	9	5		10		14c;	2		1	35	35	2			2	
H2228	001	0	1	04	01	H2228_001_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;	2		1	30	30	2			2	
H2228	001	0	1	04	01	H2228_001_0	4	2	Group 2	11	8a2;17b;	17b;	2		2			1	0.00	0.00	2	
H2228	001	0	1	04	01	H2228_001_0	4	3	Group 3	01	10a;12;		2		1	20	20	2			2	
H2228	001	0	1	04	01	H2228_001_0	4	4	Group 4	10		10b;	2		1	75	75	2			2	
H2228	001	0	1	04	01	H2228_001_0	4	5	Group 5	01	14a;		2		1	0	30	2			2	
H2228	001	0	1	04	01	H2228_001_0	4	6	Group 6	10		13b;	1	100.00	2			1	0.00	0.00	2	
H2228	002	0	1	04	01	H2228_002_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;	2		1	30	30	2			2	
H2228	002	0	1	04	01	H2228_002_0	4	2	Group 2	11	8a2;17b;	17b;	2		2			1	0.00	0.00	2	
H2228	002	0	1	04	01	H2228_002_0	4	3	Group 3	01	10a;12;		2		1	20	20	2			2	
H2228	002	0	1	04	01	H2228_002_0	4	4	Group 4	10		10b;	2		1	75	75	2			2	
H2228	002	0	1	04	01	H2228_002_0	4	5	Group 5	01	14a;		2		1	0	30	2			2	
H2228	002	0	1	04	01	H2228_002_0	4	6	Group 6	10		13b;	1	120.00	2			1	0.00	0.00	2	
H2228	010	0	1	04	01	H2228_010_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;	2		1	30	30	2			2	
H2228	010	0	1	04	01	H2228_010_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;	2		2			1	0.00	0.00	2	
H2228	010	0	1	04	01	H2228_010_0	4	3	Group 3	01	10a;12;		2		1	20	20	2			2	
H2228	010	0	1	04	01	H2228_010_0	4	4	Group 4	10		10b;	2		1	75	75	2			2	
H2228	010	0	1	04	01	H2228_010_0	4	5	Group 5	01	14a;		2		1	0	30	2			2	
H2228	010	0	1	04	01	H2228_010_0	4	6	Group 6	10		13b;	1	90.00	2			1	0.00	0.00	2	
H2228	011	0	1	04	01	H2228_011_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		1	30	30	2			2	
H2228	011	0	1	04	01	H2228_011_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H2228	011	0	1	04	01	H2228_011_0	4	3	Group 3	10		10b;	2		1	75	75	2			2	
H2228	011	0	1	04	01	H2228_011_0	4	4	Group 4	01	14a;		2		1	0	30	2			2	
H2228	011	0	1	04	01	H2228_011_0	4	5	Group 5	01	12;		2		1	20	20	2			2	
H2228	011	0	1	04	01	H2228_011_0	4	6	Group 6	01	10a;		2		2			1	100.00	100.00	2	
H2228	011	0	1	04	01	H2228_011_0	4	7	Group 7	10		13b;	1	25.00	2			1	0.00	0.00	2	
H2228	012	0	1	04	01	H2228_012_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;	2		1	30	30	2			2	
H2228	012	0	1	04	01	H2228_012_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;	2		2			1	0.00	0.00	2	
H2228	012	0	1	04	01	H2228_012_0	4	3	Group 3	10		10b;	2		1	75	75	2			2	
H2228	012	0	1	04	01	H2228_012_0	4	4	Group 4	01	14a;		2		1	0	30	2			2	
H2228	012	0	1	04	01	H2228_012_0	4	5	Group 5	01	12;		2		1	20	20	2			2	
H2228	012	0	1	04	01	H2228_012_0	4	6	Group 6	01	10a;		2		2			1	100.00	100.00	2	
H2228	012	0	1	04	01	H2228_012_0	4	7	Group 7	10		13b;	1	30.00	2			1	0.00	0.00	2	
H2228	013	0	1	04	01	H2228_013_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		1	30	30	2			2	
H2228	013	0	1	04	01	H2228_013_0	4	2	Group 2	11	8a2;17b;	17b;18b;	2		2			1	0.00	0.00	2	
H2228	013	0	1	04	01	H2228_013_0	4	3	Group 3	01	10a;12;		2		1	20	20	2			2	
H2228	013	0	1	04	01	H2228_013_0	4	4	Group 4	10		10b;	2		1	75	75	2			2	
H2228	013	0	1	04	01	H2228_013_0	4	5	Group 5	01	14a;		2		1	0	30	2			2	
H2228	013	0	1	04	01	H2228_013_0	4	6	Group 6	10		13b;	1	80.00	2			1	0.00	0.00	2	
H2228	016	0	1	04	01	H2228_016_0	5	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		1	30	30	2			2	
H2228	016	0	1	04	01	H2228_016_0	5	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H2228	016	0	1	04	01	H2228_016_0	5	3	Group 3	01	10a;12;		2		1	20	20	2			2	
H2228	016	0	1	04	01	H2228_016_0	5	4	Group 4	10		10b;	2		1	75	75	2			2	
H2228	016	0	1	04	01	H2228_016_0	5	5	Group 5	01	14a;		2		1	0	30	2			2	
H2228	016	0	1	04	01	H2228_016_0	5	6	Group 6	10		13b;	1	95.00	2			1	0.00	0.00	2	
H2228	017	0	1	04	01	H2228_017_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		1	30	30	2			2	
H2228	017	0	1	04	01	H2228_017_0	3	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H2228	017	0	1	04	01	H2228_017_0	3	3	Group 3	10		10b;	2		1	75	75	2			2	
H2228	017	0	1	04	01	H2228_017_0	3	4	Group 4	01	14a;		2		1	0	30	2			2	
H2228	017	0	1	04	01	H2228_017_0	3	5	Group 5	01	12;		2		1	20	20	2			2	
H2228	017	0	1	04	01	H2228_017_0	3	6	Group 6	01	10a;		2		2			1	100.00	100.00	2	
H2228	017	0	1	04	01	H2228_017_0	3	7	Group 7	10		13b;	1	65.00	2			1	0.00	0.00	2	
H2228	018	0	1	04	01	H2228_018_0	3	1	Group 1	01	7a;		2		2			1	30.00	30.00	2	
H2228	018	0	1	04	01	H2228_018_0	3	10	Group 10	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
H2228	018	0	1	04	01	H2228_018_0	3	11	Group 11	01	14a;		2		1	0	40	2			2	
H2228	018	0	1	04	01	H2228_018_0	3	12	Group 12	01	6;11a;		2		1	50	50	2			2	
H2228	018	0	1	04	01	H2228_018_0	3	13	Group 13	01	7g;		2		2			1	30.00	50.00	2	
H2228	018	0	1	04	01	H2228_018_0	3	14	Group 14	01	8b3;		2		2			1	21.00	21.00	2	
H2228	018	0	1	04	01	H2228_018_0	3	15		01	8a2;		2		2			1	5.00	5.00	2	
H2228	018	0	1	04	01	H2228_018_0	3	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	50.00	50.00	2	
H2228	018	0	1	04	01	H2228_018_0	3	3	Group 3	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;11b;11c;14d;15;16b;17b;	14b;	2		1	40	40	2			2	
H2228	018	0	1	04	01	H2228_018_0	3	4	Group 4	01	14e;		2		1	40	40	1	50.00	50.00	2	
H2228	018	0	1	04	01	H2228_018_0	3	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
H2228	018	0	1	04	01	H2228_018_0	3	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H2228	018	0	1	04	01	H2228_018_0	3	7	Group 7	01	10a;		2		2			1	225.00	225.00	2	
H2228	018	0	1	04	01	H2228_018_0	3	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H2228	018	0	1	04	01	H2228_018_0	3	9	Group 9	01	12;		2		1	20	20	2			2	
H2228	019	0	1	04	01	H2228_019_0	3	1	Group 1	01	7a;7g;		2		2			1	25.00	60.00	2	
H2228	019	0	1	04	01	H2228_019_0	3	10	Group 10	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
H2228	019	0	1	04	01	H2228_019_0	3	11	Group 11	01	14a;		2		1	0	40	2			2	
H2228	019	0	1	04	01	H2228_019_0	3	12	Group 12	01	6;11a;		2		1	50	50	2			2	
H2228	019	0	1	04	01	H2228_019_0	3	13	Group 13	10		13b;	1	40.00	2			1	0.00	0.00	2	
H2228	019	0	1	04	01	H2228_019_0	3	14	Group 14	10		18b;	2		2			1	330.00	380.00	2	
H2228	019	0	1	04	01	H2228_019_0	3	15	Group 15	01	14e;		2		1	40	40	1	60.00	60.00	2	
H2228	019	0	1	04	01	H2228_019_0	3	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	60.00	60.00	2	
H2228	019	0	1	04	01	H2228_019_0	3	3	Group 3	11	3-1;3-2;3-3;9a;9b;11b;11c;14d;15;16b;17b;	14b;17b;	2		1	40	40	2			2	
H2228	019	0	1	04	01	H2228_019_0	3	4	Group 4	01	8a1;8a2;8b1;8b2;8b3;		2		1	40	40	1	5.00	21.00	2	
H2228	019	0	1	04	01	H2228_019_0	3	5	Group 5	10		16a;	2		1	75	75	2			2	
H2228	019	0	1	04	01	H2228_019_0	3	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H2228	019	0	1	04	01	H2228_019_0	3	7	Group 7	01	10a;		2		2			1	250.00	250.00	2	
H2228	019	0	1	04	01	H2228_019_0	3	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H2228	019	0	1	04	01	H2228_019_0	3	9	Group 9	01	12;		2		1	20	20	2			2	
H2228	020	0	1	04	01	H2228_020_0	4	1	Group 1	01	7a;		2		2			1	30.00	30.00	2	
H2228	020	0	1	04	01	H2228_020_0	4	10	Group 10	11	9d;	9d;14c;16a;16b;	2		2			1	0.00	0.00	2	
H2228	020	0	1	04	01	H2228_020_0	4	11	Group 11	01	14a;		2		1	0	40	2			2	
H2228	020	0	1	04	01	H2228_020_0	4	12	Group 12	01	6;11a;		2		1	50	50	2			2	
H2228	020	0	1	04	01	H2228_020_0	4	13	Group 13	01	14e;		2		1	40	40	1	55.00	55.00	2	
H2228	020	0	1	04	01	H2228_020_0	4	14	Group 14	01	7g;		2		2			1	30.00	55.00	2	
H2228	020	0	1	04	01	H2228_020_0	4	15	Group 15	10		13b;	1	100.00	2			1	0.00	0.00	2	
H2228	020	0	1	04	01	H2228_020_0	4	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	55.00	55.00	2	
H2228	020	0	1	04	01	H2228_020_0	4	3	Group 3	11	3-1;3-2;3-3;9a;9b;11b;11c;14d;15;16b;17b;	14b;17b;	2		1	40	40	2			2	
H2228	020	0	1	04	01	H2228_020_0	4	4	Group 4	01	8a1;8a2;8b1;8b2;8b3;		2		1	40	40	1	2.00	18.00	2	
H2228	020	0	1	04	01	H2228_020_0	4	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
H2228	020	0	1	04	01	H2228_020_0	4	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H2228	020	0	1	04	01	H2228_020_0	4	7	Group 7	01	10a;		2		2			1	250.00	250.00	2	
H2228	020	0	1	04	01	H2228_020_0	4	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H2228	020	0	1	04	01	H2228_020_0	4	9	Group 9	01	12;		2		1	20	20	2			2	
H2228	021	0	1	04	01	H2228_021_0	3	1	Group 1	01	7a;7g;		2		2			1	25.00	60.00	2	
H2228	021	0	1	04	01	H2228_021_0	3	10	Group 10	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
H2228	021	0	1	04	01	H2228_021_0	3	11	Group 11	01	14a;		2		1	0	40	2			2	
H2228	021	0	1	04	01	H2228_021_0	3	12	Group 12	01	6;11a;		2		1	50	50	2			2	
H2228	021	0	1	04	01	H2228_021_0	3	13	Group 13	01	14e;		2		1	40	40	1	60.00	60.00	2	
H2228	021	0	1	04	01	H2228_021_0	3	14	Group 14	10		13b;	1	40.00	2			1	0.00	0.00	2	
H2228	021	0	1	04	01	H2228_021_0	3	15	Group 15	01	8b3;		2		2			1	21.00	21.00	2	
H2228	021	0	1	04	01	H2228_021_0	3	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	60.00	60.00	2	
H2228	021	0	1	04	01	H2228_021_0	3	3	Group 3	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;11b;11c;14d;15;16b;17b;	14b;17b;	2		1	40	40	2			2	
H2228	021	0	1	04	01	H2228_021_0	3	4	Group 4	01	8a2;		2		2			1	5.00	5.00	2	
H2228	021	0	1	04	01	H2228_021_0	3	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
H2228	021	0	1	04	01	H2228_021_0	3	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H2228	021	0	1	04	01	H2228_021_0	3	7	Group 7	01	10a;		2		2			1	200.00	200.00	2	
H2228	021	0	1	04	01	H2228_021_0	3	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H2228	021	0	1	04	01	H2228_021_0	3	9	Group 9	01	12;		2		1	20	20	2			2	
H2228	022	0	1	04	01	H2228_022_0	4	1	Group 1	01	7a;		2		2			1	30.00	30.00	2	
H2228	022	0	1	04	01	H2228_022_0	4	10	Group 10	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
H2228	022	0	1	04	01	H2228_022_0	4	11	Group 11	01	14a;		2		1	0	40	2			2	
H2228	022	0	1	04	01	H2228_022_0	4	12	Group 12	10		16a;	2		1	75	75	2			2	
H2228	022	0	1	04	01	H2228_022_0	4	13	Group 13	01	14e;		2		1	40	40	1	60.00	60.00	2	
H2228	022	0	1	04	01	H2228_022_0	4	14	Group 14	01	7g;		2		2			1	30.00	60.00	2	
H2228	022	0	1	04	01	H2228_022_0	4	15	Group 15	10		13b;	1	40.00	2			1	0.00	0.00	2	
H2228	022	0	1	04	01	H2228_022_0	4	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	60.00	60.00	2	
H2228	022	0	1	04	01	H2228_022_0	4	3	Group 3	11	3-1;3-2;3-3;9a;9b;11b;11c;14d;15;16b;17b;	14b;17b;	2		1	40	40	2			2	
H2228	022	0	1	04	01	H2228_022_0	4	4	Group 4	01	8a1;8a2;8b1;8b2;8b3;		2		1	40	40	1	5.00	21.00	2	
H2228	022	0	1	04	01	H2228_022_0	4	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
H2228	022	0	1	04	01	H2228_022_0	4	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H2228	022	0	1	04	01	H2228_022_0	4	7	Group 7	01	10a;		2		2			1	250.00	250.00	2	
H2228	022	0	1	04	01	H2228_022_0	4	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H2228	022	0	1	04	01	H2228_022_0	4	9	Group 9	01	6;11a;12;		2		1	20	50	2			2	
H2228	023	0	1	04	01	H2228_023_0	5	1	Group 1	10		13b;	1	100.00	2			1	0.00	0.00	2	
H2228	023	0	1	04	01	H2228_023_0	5	10	Group 10	11	8a2;9d;	9d;14c;16a;16b;	2		2			1	0.00	0.00	2	
H2228	023	0	1	04	01	H2228_023_0	5	11	Group 11	01	14a;		2		1	0	40	2			2	
H2228	023	0	1	04	01	H2228_023_0	5	12	Group 12	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;14d;16b;	14b;	2		1	40	40	2			2	
H2228	023	0	1	04	01	H2228_023_0	5	13	Group 13	10		10b;	2		1	75	75	2			2	
H2228	023	0	1	04	01	H2228_023_0	5	14	Group 14	01	7a;7g;		2		2			1	25.00	65.00	2	
H2228	023	0	1	04	01	H2228_023_0	5	15	Group 15	01	14e;		2		1	40	40	1	65.00	65.00	2	
H2228	023	0	1	04	01	H2228_023_0	5	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	65.00	65.00	2	
H2228	023	0	1	04	01	H2228_023_0	5	3	Group 3	01	11b;11c;15;17b;		2		1	30	30	2			2	
H2228	023	0	1	04	01	H2228_023_0	5	4	Group 4	01	8b3;		2		2			1	7.00	7.00	2	
H2228	023	0	1	04	01	H2228_023_0	5	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
H2228	023	0	1	04	01	H2228_023_0	5	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H2228	023	0	1	04	01	H2228_023_0	5	7	Group 7	01	10a;		2		2			1	190.00	190.00	2	
H2228	023	0	1	04	01	H2228_023_0	5	8	Group 8	01	7e;7h;9c;		2		2			1	20.00	30.00	2	
H2228	023	0	1	04	01	H2228_023_0	5	9	Group 9	01	6;11a;12;		2		1	20	50	2			2	
H2228	024	0	1	04	01	H2228_024_0	3	1	Group 1	01	7a;		2		2			1	40.00	40.00	2	
H2228	024	0	1	04	01	H2228_024_0	3	10	Group 10	11	9d;	9d;14c;17b;	2		2			1	0.00	0.00	2	
H2228	024	0	1	04	01	H2228_024_0	3	11	Group 11	01	14a;		2		1	0	40	2			2	
H2228	024	0	1	04	01	H2228_024_0	3	12	Group 12	01	6;11a;		2		1	50	50	2			2	
H2228	024	0	1	04	01	H2228_024_0	3	13	Group 13	01	7g;		2		2			1	40.00	70.00	2	
H2228	024	0	1	04	01	H2228_024_0	3	14	Group 14	10		13b;	1	40.00	2			1	0.00	0.00	2	
H2228	024	0	1	04	01	H2228_024_0	3	15	Group #15	01	14e;		2		1	40	40	1	70.00	70.00	2	
H2228	024	0	1	04	01	H2228_024_0	3	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7b;7f;13a;17a;18a;	2		2			1	70.00	70.00	2	
H2228	024	0	1	04	01	H2228_024_0	3	3	Group 3	11	3-1;3-2;3-3;9a;9b;11b;11c;14d;15;16b;17b;	14b;	2		1	40	40	2			2	
H2228	024	0	1	04	01	H2228_024_0	3	4	Group 4	01	8a1;8a2;8b1;8b2;8b3;		2		1	40	40	1	16.00	30.00	2	
H2228	024	0	1	04	01	H2228_024_0	3	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
H2228	024	0	1	04	01	H2228_024_0	3	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H2228	024	0	1	04	01	H2228_024_0	3	7	Group 7	01	10a;		2		2			1	225.00	225.00	2	
H2228	024	0	1	04	01	H2228_024_0	3	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H2228	024	0	1	04	01	H2228_024_0	3	9	Group 9	01	12;		2		1	20	20	2			2	
H2228	025	0	1	04	01	H2228_025_0	2	1	Group 1	01	7a;		2		2			1	40.00	40.00	2	
H2228	025	0	1	04	01	H2228_025_0	2	10	Group 10	11	9d;	9d;14c;17b;	2		2			1	0.00	0.00	2	
H2228	025	0	1	04	01	H2228_025_0	2	11	Group 11	01	14a;		2		1	0	40	2			2	
H2228	025	0	1	04	01	H2228_025_0	2	12	Group 12	01	6;11a;		2		1	50	50	2			2	
H2228	025	0	1	04	01	H2228_025_0	2	13	Group 13	01	7g;		2		2			1	40.00	70.00	2	
H2228	025	0	1	04	01	H2228_025_0	2	14	Group 14	01	8b3;		2		2			1	30.00	30.00	2	
H2228	025	0	1	04	01	H2228_025_0	2	15	Group 15	01	14e;		2		1	40	40	1	70.00	70.00	2	
H2228	025	0	1	04	01	H2228_025_0	2	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7b;7f;13a;17a;18a;	2		2			1	70.00	70.00	2	
H2228	025	0	1	04	01	H2228_025_0	2	3	Group 3	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;11b;11c;14d;15;16b;17b;	14b;	2		1	40	40	2			2	
H2228	025	0	1	04	01	H2228_025_0	2	4	Group 4	01	8a2;		2		2			1	25.00	25.00	2	
H2228	025	0	1	04	01	H2228_025_0	2	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
H2228	025	0	1	04	01	H2228_025_0	2	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H2228	025	0	1	04	01	H2228_025_0	2	7	Group 7	01	10a;		2		2			1	225.00	225.00	2	
H2228	025	0	1	04	01	H2228_025_0	2	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H2228	025	0	1	04	01	H2228_025_0	2	9	Group 9	01	12;		2		1	20	20	2			2	
H2228	029	0	1	04	01	H2228_029_0	3	1	Group 1	01	7a;7g;		2		2			1	25.00	50.00	2	
H2228	029	0	1	04	01	H2228_029_0	3	10	Group 10	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
H2228	029	0	1	04	01	H2228_029_0	3	11	Group 11	01	14a;		2		1	0	30	2			2	
H2228	029	0	1	04	01	H2228_029_0	3	12	Group 12	01	6;11a;		2		1	50	50	2			2	
H2228	029	0	1	04	01	H2228_029_0	3	13	Group 13	01	8a2;		2		2			1	5.00	5.00	2	
H2228	029	0	1	04	01	H2228_029_0	3	14	Group 14	01	8b3;		2		2			1	21.00	21.00	2	
H2228	029	0	1	04	01	H2228_029_0	3	15		01	14e;		2		1	30	30	1	50.00	50.00	2	
H2228	029	0	1	04	01	H2228_029_0	3	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7b;7f;13a;17a;18a;	2		2			1	50.00	50.00	2	
H2228	029	0	1	04	01	H2228_029_0	3	3	Group 3	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;11b;11c;14d;15;16b;17b;	14b;	2		1	30	30	2			2	
H2228	029	0	1	04	01	H2228_029_0	3	4	Group 4	10		13b;	1	50.00	2			1	0.00	0.00	2	
H2228	029	0	1	04	01	H2228_029_0	3	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
H2228	029	0	1	04	01	H2228_029_0	3	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H2228	029	0	1	04	01	H2228_029_0	3	7	Group 7	01	10a;		2		2			1	250.00	250.00	2	
H2228	029	0	1	04	01	H2228_029_0	3	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H2228	029	0	1	04	01	H2228_029_0	3	9	Group 9	01	12;		2		1	20	20	2			2	
H2228	030	0	1	04	01	H2228_030_0	4	1	Group 1	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8b1;8b2;9a;9b;11b;11c;14d;14e;15;16b;17a;17b;18a;	7f;14b;17a;17b;18a;	2		1	30	30	2			2	
H2228	030	0	1	04	01	H2228_030_0	4	10	Group 10	01	6;11a;		2		1	50	50	2			2	
H2228	030	0	1	04	01	H2228_030_0	4	11	Group 11	10		18b;	2		2			1	100.00	150.00	2	
H2228	030	0	1	04	01	H2228_030_0	4	12	Group 12	10		13b;	1	50.00	2			1	0.00	0.00	2	
H2228	030	0	1	04	01	H2228_030_0	4	2	Group 2	01	8b3;		2		2			1	21.00	21.00	2	
H2228	030	0	1	04	01	H2228_030_0	4	3	Group 3	10		16a;	2		1	75	75	2			2	
H2228	030	0	1	04	01	H2228_030_0	4	4	Group 4	01	5;		2		2			1	75.00	75.00	2	
H2228	030	0	1	04	01	H2228_030_0	4	5	Group 5	01	10a;		2		2			1	225.00	225.00	2	
H2228	030	0	1	04	01	H2228_030_0	4	6	Group 6	01	7e;7h;9c;		2		2			1	20.00	30.00	2	
H2228	030	0	1	04	01	H2228_030_0	4	7	Group 7	01	12;		2		1	20	20	2			2	
H2228	030	0	1	04	01	H2228_030_0	4	8	Group 8	11	8a2;9d;	9d;14c;	2		2			1	0.00	0.00	2	
H2228	030	0	1	04	01	H2228_030_0	4	9	Group 9	01	14a;		2		1	0	30	2			2	
H2228	031	0	1	04	01	H2228_031_0	3	1	Group 1	01	7a;		2		2			1	35.00	35.00	2	
H2228	031	0	1	04	01	H2228_031_0	3	10	Group 10	11	8a2;9d;17b;	9d;14c;	2		2			1	0.00	0.00	2	
H2228	031	0	1	04	01	H2228_031_0	3	11	Group 11	01	14a;		2		1	0	30	2			2	
H2228	031	0	1	04	01	H2228_031_0	3	12	Group 12	01	6;11a;		2		1	50	50	2			2	
H2228	031	0	1	04	01	H2228_031_0	3	13	Group 13	01	7g;		2		2			1	35.00	65.00	2	
H2228	031	0	1	04	01	H2228_031_0	3	14	Group 14	10		13b;	1	50.00	2			1	0.00	0.00	2	
H2228	031	0	1	04	01	H2228_031_0	3	15	Group 15	01	14e;		2		1	30	30	1	65.00	65.00	2	
H2228	031	0	1	04	01	H2228_031_0	3	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	65.00	65.00	2	
H2228	031	0	1	04	01	H2228_031_0	3	3	Group 3	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;11b;11c;14d;15;16b;	14b;17b;	2		1	30	30	2			2	
H2228	031	0	1	04	01	H2228_031_0	3	4	Group 4	01	8b3;		2		2			1	21.00	21.00	2	
H2228	031	0	1	04	01	H2228_031_0	3	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
H2228	031	0	1	04	01	H2228_031_0	3	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H2228	031	0	1	04	01	H2228_031_0	3	7	Group 7	01	10a;		2		2			1	250.00	250.00	2	
H2228	031	0	1	04	01	H2228_031_0	3	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H2228	031	0	1	04	01	H2228_031_0	3	9	Group 9	01	12;		2		1	20	20	2			2	
H2228	032	0	1	04	01	H2228_032_0	3	1	Group 1	01	7a;7g;		2		2			1	25.00	60.00	2	
H2228	032	0	1	04	01	H2228_032_0	3	10	Group 10	11	8a2;9d;17b;	9d;14c;	2		2			1	0.00	0.00	2	
H2228	032	0	1	04	01	H2228_032_0	3	11	Group 11	01	14a;		2		1	0	30	2			2	
H2228	032	0	1	04	01	H2228_032_0	3	12	Group 12	01	6;11a;		2		1	50	50	2			2	
H2228	032	0	1	04	01	H2228_032_0	3	13	Group 13	01	14e;		2		1	30	30	1	60.00	60.00	2	
H2228	032	0	1	04	01	H2228_032_0	3	14	Group 14	10		18b;	2		2			1	330.00	380.00	2	
H2228	032	0	1	04	01	H2228_032_0	3	15	Group 15	10		13b;	1	50.00	2			1	0.00	0.00	2	
H2228	032	0	1	04	01	H2228_032_0	3	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	60.00	60.00	2	
H2228	032	0	1	04	01	H2228_032_0	3	3	Group 3	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;11b;11c;14d;15;16b;	14b;17b;	2		1	30	30	2			2	
H2228	032	0	1	04	01	H2228_032_0	3	4	Group 4	01	8b3;		2		2			1	21.00	21.00	2	
H2228	032	0	1	04	01	H2228_032_0	3	5	Group 5	10		16a;	2		2			1	40.00	40.00	2	
H2228	032	0	1	04	01	H2228_032_0	3	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H2228	032	0	1	04	01	H2228_032_0	3	7	Group 7	01	10a;		2		2			1	225.00	225.00	2	
H2228	032	0	1	04	01	H2228_032_0	3	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H2228	032	0	1	04	01	H2228_032_0	3	9	Group 9	01	12;		2		1	20	20	2			2	
H2228	033	0	1	04	01	H2228_033_0	3	1	Group 1	01	7a;7g;		2		2			1	45.00	70.00	2	
H2228	033	0	1	04	01	H2228_033_0	3	10	Group 10	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
H2228	033	0	1	04	01	H2228_033_0	3	11	Group 11	01	6;11a;15;		2		1	50	50	2			2	
H2228	033	0	1	04	01	H2228_033_0	3	12	Group 12	01	14a;		2		1	0	40	2			2	
H2228	033	0	1	04	01	H2228_033_0	3	13	Group 13	01	8a2;		2		2			1	5.00	5.00	2	
H2228	033	0	1	04	01	H2228_033_0	3	14	Group 14	10		16a;	2		2			1	40.00	40.00	2	
H2228	033	0	1	04	01	H2228_033_0	3	15	Group 15	01	14e;		2		1	40	40	1	70.00	70.00	2	
H2228	033	0	1	04	01	H2228_033_0	3	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	70.00	70.00	2	
H2228	033	0	1	04	01	H2228_033_0	3	3	Group 3	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;11b;11c;14d;16b;17b;	14b;	2		1	40	40	2			2	
H2228	033	0	1	04	01	H2228_033_0	3	4	Group 4	01	8b3;		2		2			1	21.00	21.00	2	
H2228	033	0	1	04	01	H2228_033_0	3	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
H2228	033	0	1	04	01	H2228_033_0	3	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H2228	033	0	1	04	01	H2228_033_0	3	7	Group 7	01	10a;		2		2			1	225.00	225.00	2	
H2228	033	0	1	04	01	H2228_033_0	3	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H2228	033	0	1	04	01	H2228_033_0	3	9	Group 9	01	12;		2		1	20	20	2			2	
H2228	035	0	1	04	01	H2228_035_0	4	1	Group 1	01	7a;7g;		2		2			1	45.00	70.00	2	
H2228	035	0	1	04	01	H2228_035_0	4	10	Group 10	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
H2228	035	0	1	04	01	H2228_035_0	4	11	Group 11	01	14a;		2		1	0	40	2			2	
H2228	035	0	1	04	01	H2228_035_0	4	12	Group 12	10		13b;	1	135.00	2			1	0.00	0.00	2	
H2228	035	0	1	04	01	H2228_035_0	4	13	Group 13	01	14e;		2		1	40	40	1	70.00	70.00	2	
H2228	035	0	1	04	01	H2228_035_0	4	14	Group 14	10		18b;	2		2			1	330.00	380.00	2	
H2228	035	0	1	04	01	H2228_035_0	4	15	Group 15	01	8a2;		2		2			1	5.00	5.00	2	
H2228	035	0	1	04	01	H2228_035_0	4	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	70.00	70.00	2	
H2228	035	0	1	04	01	H2228_035_0	4	3	Group 3	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;11b;11c;14d;15;16b;17b;	14b;	2		1	40	40	2			2	
H2228	035	0	1	04	01	H2228_035_0	4	4	Group 4	01	8b3;		2		2			1	21.00	21.00	2	
H2228	035	0	1	04	01	H2228_035_0	4	5	Group 5	01	6;11a;		2		1	50	50	2			2	
H2228	035	0	1	04	01	H2228_035_0	4	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H2228	035	0	1	04	01	H2228_035_0	4	7	Group 7	01	10a;		2		2			1	225.00	225.00	2	
H2228	035	0	1	04	01	H2228_035_0	4	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H2228	035	0	1	04	01	H2228_035_0	4	9	Group 9	01	12;		2		1	20	20	2			2	
H2228	036	0	1	04	01	H2228_036_0	3	1	Group 1	01	7a;7g;		2		2			1	15.00	55.00	2	
H2228	036	0	1	04	01	H2228_036_0	3	10	Group 10	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
H2228	036	0	1	04	01	H2228_036_0	3	11	Group 11	01	14a;		2		1	0	30	2			2	
H2228	036	0	1	04	01	H2228_036_0	3	12	Group 12	10		16a;	2		1	75	75	2			2	
H2228	036	0	1	04	01	H2228_036_0	3	13	Group 13	01	14e;		2		1	30	30	1	55.00	55.00	2	
H2228	036	0	1	04	01	H2228_036_0	3	14	Group 14	10		18b;	2		2			1	330.00	380.00	2	
H2228	036	0	1	04	01	H2228_036_0	3	15	Group 15	01	8a2;		2		2			1	5.00	5.00	2	
H2228	036	0	1	04	01	H2228_036_0	3	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	55.00	55.00	2	
H2228	036	0	1	04	01	H2228_036_0	3	3	Group 3	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;11b;11c;14d;15;16b;17b;	14b;17b;	2		1	30	30	2			2	
H2228	036	0	1	04	01	H2228_036_0	3	4	Group 4	01	8b3;		2		2			1	21.00	21.00	2	
H2228	036	0	1	04	01	H2228_036_0	3	5	Group 5	01	12;		2		1	20	20	2			2	
H2228	036	0	1	04	01	H2228_036_0	3	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H2228	036	0	1	04	01	H2228_036_0	3	7	Group 7	01	10a;		2		2			1	225.00	225.00	2	
H2228	036	0	1	04	01	H2228_036_0	3	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H2228	036	0	1	04	01	H2228_036_0	3	9	Group 9	01	6;11a;		2		1	50	50	2			2	
H2228	037	0	1	04	01	H2228_037_0	3	1	Group 1	01	7a;7g;		2		2			1	45.00	70.00	2	
H2228	037	0	1	04	01	H2228_037_0	3	10	Group 10	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
H2228	037	0	1	04	01	H2228_037_0	3	11	Group 11	01	14a;		2		1	0	40	2			2	
H2228	037	0	1	04	01	H2228_037_0	3	12	Group 12	10		16a;	2		1	75	75	2			2	
H2228	037	0	1	04	01	H2228_037_0	3	13	Group 13	01	14e;		2		1	40	40	1	70.00	70.00	2	
H2228	037	0	1	04	01	H2228_037_0	3	14	Group 14	10		18b;	2		2			1	330.00	380.00	2	
H2228	037	0	1	04	01	H2228_037_0	3	15	Group 15	01	8a2;		2		2			1	5.00	5.00	2	
H2228	037	0	1	04	01	H2228_037_0	3	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	70.00	70.00	2	
H2228	037	0	1	04	01	H2228_037_0	3	3	Group 3	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;11b;11c;14d;15;16b;17b;	14b;17b;	2		1	40	40	2			2	
H2228	037	0	1	04	01	H2228_037_0	3	4	Group 4	01	8b3;		2		2			1	21.00	21.00	2	
H2228	037	0	1	04	01	H2228_037_0	3	5	Group 5	01	6;11a;		2		1	50	50	2			2	
H2228	037	0	1	04	01	H2228_037_0	3	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H2228	037	0	1	04	01	H2228_037_0	3	7	Group 7	01	10a;		2		2			1	225.00	225.00	2	
H2228	037	0	1	04	01	H2228_037_0	3	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H2228	037	0	1	04	01	H2228_037_0	3	9	Group 9	01	12;		2		1	20	20	2			2	
H2228	039	0	1	04	01	H2228_039_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		1	30	30	2			2	
H2228	039	0	1	04	01	H2228_039_0	4	2	Group 2	11	8a2;17b;	17b;18b;	2		2			1	0.00	0.00	2	
H2228	039	0	1	04	01	H2228_039_0	4	3	Group 3	10		10b;	2		1	75	75	2			2	
H2228	039	0	1	04	01	H2228_039_0	4	4	Group 4	01	14a;		2		1	0	30	2			2	
H2228	039	0	1	04	01	H2228_039_0	4	5	Group 5	01	12;		2		1	20	20	2			2	
H2228	039	0	1	04	01	H2228_039_0	4	6	Group 6	01	10a;		2		2			1	100.00	100.00	2	
H2228	039	0	1	04	01	H2228_039_0	4	7	Group 7	10		13b;	1	30.00	2			1	0.00	0.00	2	
H2228	041	0	1	04	01	H2228_041_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;16b;17a;18a;	7b;7f;9d;13a;17a;18a;	2		1	30	30	2			2	
H2228	041	0	1	04	01	H2228_041_0	3	2	Group 2	01	14a;		2		1	0	30	2			2	
H2228	041	0	1	04	01	H2228_041_0	3	3	Group 3	10		10b;	2		1	75	75	2			2	
H2228	041	0	1	04	01	H2228_041_0	3	4	Group 4	01	10a;12;15;		2		1	20	20	2			2	
H2228	041	0	1	04	01	H2228_041_0	3	5	Group 5	11	8a2;17b;	14c;16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H2228	041	0	1	04	01	H2228_041_0	3	6	Group 6	10		13b;	1	250.00	2			1	0.00	0.00	2	
H2228	042	0	1	04	01	H2228_042_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;16b;17a;18a;	7f;9d;17a;18a;	2		1	30	30	2			2	
H2228	042	0	1	04	01	H2228_042_0	3	2	Group 2	01	14a;		2		1	0	30	2			2	
H2228	042	0	1	04	01	H2228_042_0	3	3	Group 3	10		10b;	2		1	75	75	2			2	
H2228	042	0	1	04	01	H2228_042_0	3	4	Group 4	01	10a;12;15;		2		1	20	20	2			2	
H2228	042	0	1	04	01	H2228_042_0	3	5	Group 5	11	8a2;17b;	14c;16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H2228	042	0	1	04	01	H2228_042_0	3	6	Group 6	10		13b;	1	150.00	2			1	0.00	0.00	2	
H2228	043	0	1	04	01	H2228_043_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;16b;17a;18a;	7b;7f;9d;13a;	2		1	30	30	2			2	
H2228	043	0	1	04	01	H2228_043_0	3	2	Group 2	01	14a;		2		1	0	30	2			2	
H2228	043	0	1	04	01	H2228_043_0	3	3	Group 3	10		13b;	1	150.00	2			1	0.00	0.00	2	
H2228	043	0	1	04	01	H2228_043_0	3	4	Group 4	01	10a;12;15;		2		1	20	20	2			2	
H2228	043	0	1	04	01	H2228_043_0	3	5	Group 5	11	8a2;17b;	14c;16a;16b;	2		2			1	0.00	0.00	2	
H2228	044	0	1	04	01	H2228_044_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;16b;17a;18a;	7f;9d;17a;18a;	2		1	30	30	2			2	
H2228	044	0	1	04	01	H2228_044_0	3	2	Group 2	01	14a;		2		1	0	30	2			2	
H2228	044	0	1	04	01	H2228_044_0	3	3	Group 3	10		10b;	2		1	75	75	2			2	
H2228	044	0	1	04	01	H2228_044_0	3	4	Group 4	01	10a;12;15;		2		1	20	20	2			2	
H2228	044	0	1	04	01	H2228_044_0	3	5	Group 5	11	8a2;17b;	14c;16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H2228	044	0	1	04	01	H2228_044_0	3	6	Group 6	10		13b;	1	165.00	2			1	0.00	0.00	2	
H2228	045	0	1	04	01	H2228_045_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;16b;17a;18a;	7f;9d;17a;	2		1	30	30	2			2	
H2228	045	0	1	04	01	H2228_045_0	3	2	Group 2	01	14a;		2		1	0	30	2			2	
H2228	045	0	1	04	01	H2228_045_0	3	3	Group 3	10		10b;	2		1	75	75	2			2	
H2228	045	0	1	04	01	H2228_045_0	3	4	Group 4	01	10a;12;15;		2		1	20	20	2			2	
H2228	045	0	1	04	01	H2228_045_0	3	5	Group 5	11	8a2;17b;	14c;16a;16b;17b;	2		2			1	0.00	0.00	2	
H2228	045	0	1	04	01	H2228_045_0	3	6	Group 6	10		13b;	1	125.00	2			1	0.00	0.00	2	
H2228	046	0	1	04	01	H2228_046_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;16b;17a;18a;	7f;9d;17a;18a;	2		1	30	30	2			2	
H2228	046	0	1	04	01	H2228_046_0	3	2	Group 2	01	14a;		2		1	0	30	2			2	
H2228	046	0	1	04	01	H2228_046_0	3	3	Group 3	10		10b;	2		1	75	75	2			2	
H2228	046	0	1	04	01	H2228_046_0	3	4	Group 4	01	10a;12;15;		2		1	20	20	2			2	
H2228	046	0	1	04	01	H2228_046_0	3	5	Group 5	11	8a2;17b;	14c;16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H2228	046	0	1	04	01	H2228_046_0	3	6	Group 6	10		13b;	1	200.00	2			1	0.00	0.00	2	
H2228	047	0	1	04	01	H2228_047_0	4	1	Group 1	01	7a;		2		2			1	35.00	35.00	2	
H2228	047	0	1	04	01	H2228_047_0	4	10	Group 10	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
H2228	047	0	1	04	01	H2228_047_0	4	11	Group 11	01	14a;		2		1	0	40	2			2	
H2228	047	0	1	04	01	H2228_047_0	4	12	Group 12	11	3-1;3-2;3-3;9a;9b;14d;16b;	14b;	2		1	40	40	2			2	
H2228	047	0	1	04	01	H2228_047_0	4	13	Group 13	01	6;11a;		2		1	50	50	2			2	
H2228	047	0	1	04	01	H2228_047_0	4	14	Group 14	01	7g;		2		2			1	35.00	70.00	2	
H2228	047	0	1	04	01	H2228_047_0	4	15	Group 15	01	14e;		2		1	40	40	1	70.00	70.00	2	
H2228	047	0	1	04	01	H2228_047_0	4	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	70.00	70.00	2	
H2228	047	0	1	04	01	H2228_047_0	4	3	Group 3	01	11b;11c;15;17b;		2		1	30	30	2			2	
H2228	047	0	1	04	01	H2228_047_0	4	4	Group 4	01	8a1;8a2;8b1;8b2;8b3;		2		1	40	40	1	5.00	21.00	2	
H2228	047	0	1	04	01	H2228_047_0	4	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
H2228	047	0	1	04	01	H2228_047_0	4	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H2228	047	0	1	04	01	H2228_047_0	4	7	Group 7	01	10a;		2		2			1	250.00	250.00	2	
H2228	047	0	1	04	01	H2228_047_0	4	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H2228	047	0	1	04	01	H2228_047_0	4	9	Group 9	01	12;		2		1	20	20	2			2	
H2228	048	0	1	04	01	H2228_048_0	5	1	Group 1	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8b1;8b2;9a;9b;11b;11c;14d;14e;15;16b;17a;17b;18a;	7f;14b;17a;17b;18a;	2		1	30	30	2			2	
H2228	048	0	1	04	01	H2228_048_0	5	10	Group 10	01	6;11a;		2		1	50	50	2			2	
H2228	048	0	1	04	01	H2228_048_0	5	11	Group 11	10		18b;	2		2			1	100.00	150.00	2	
H2228	048	0	1	04	01	H2228_048_0	5	12	Group 12	10		13b;	1	50.00	2			1	0.00	0.00	2	
H2228	048	0	1	04	01	H2228_048_0	5	2	Group 2	01	8b3;		2		2			1	21.00	21.00	2	
H2228	048	0	1	04	01	H2228_048_0	5	3	Group 3	10		16a;	2		1	75	75	2			2	
H2228	048	0	1	04	01	H2228_048_0	5	4	Group 4	01	5;		2		2			1	75.00	75.00	2	
H2228	048	0	1	04	01	H2228_048_0	5	5	Group 5	01	10a;		2		2			1	225.00	225.00	2	
H2228	048	0	1	04	01	H2228_048_0	5	6	Group 6	01	7e;7h;9c;		2		2			1	20.00	30.00	2	
H2228	048	0	1	04	01	H2228_048_0	5	7	Group 7	01	12;		2		1	20	20	2			2	
H2228	048	0	1	04	01	H2228_048_0	5	8	Group 8	11	8a2;9d;	9d;14c;	2		2			1	0.00	0.00	2	
H2228	048	0	1	04	01	H2228_048_0	5	9	Group 9	01	14a;		2		1	0	30	2			2	
H2228	049	0	1	04	01	H2228_049_0	4	1	Group 1	01	7a;		2		2			1	35.00	35.00	2	
H2228	049	0	1	04	01	H2228_049_0	4	10	Group 10	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
H2228	049	0	1	04	01	H2228_049_0	4	11	Group 11	01	14a;		2		1	0	40	2			2	
H2228	049	0	1	04	01	H2228_049_0	4	12	Group 12	11	3-1;3-2;3-3;9a;9b;14d;16b;	14b;	2		1	40	40	2			2	
H2228	049	0	1	04	01	H2228_049_0	4	13	Group 13	01	6;11a;		2		1	50	50	2			2	
H2228	049	0	1	04	01	H2228_049_0	4	14	Group 14	01	7g;		2		2			1	35.00	70.00	2	
H2228	049	0	1	04	01	H2228_049_0	4	15	Group 15	01	14e;		2		1	40	40	1	70.00	70.00	2	
H2228	049	0	1	04	01	H2228_049_0	4	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	70.00	70.00	2	
H2228	049	0	1	04	01	H2228_049_0	4	3	Group 3	01	11b;11c;15;17b;		2		1	30	30	2			2	
H2228	049	0	1	04	01	H2228_049_0	4	4	Group 4	01	8a1;8a2;8b1;8b2;8b3;		2		1	40	40	1	5.00	21.00	2	
H2228	049	0	1	04	01	H2228_049_0	4	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
H2228	049	0	1	04	01	H2228_049_0	4	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H2228	049	0	1	04	01	H2228_049_0	4	7	Group 7	01	10a;		2		2			1	250.00	250.00	2	
H2228	049	0	1	04	01	H2228_049_0	4	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H2228	049	0	1	04	01	H2228_049_0	4	9	Group 9	01	12;		2		1	20	20	2			2	
H2228	805	0	1	04	01	H2228_805_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2228	805	0	1	04	01	H2228_805_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2228	807	0	1	04	01	H2228_807_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2228	807	0	1	04	01	H2228_807_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2228	808	0	1	04	01	H2228_808_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2228	808	0	1	04	01	H2228_808_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2228	809	0	2	04	01	H2228_809_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2228	809	0	2	04	01	H2228_809_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2228	810	0	2	04	01	H2228_810_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2228	810	0	2	04	01	H2228_810_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2228	811	0	2	04	01	H2228_811_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2228	811	0	2	04	01	H2228_811_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2228	812	0	1	04	01	H2228_812_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2228	812	0	1	04	01	H2228_812_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2228	813	0	1	04	01	H2228_813_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2228	813	0	1	04	01	H2228_813_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2228	814	0	1	04	01	H2228_814_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2228	814	0	1	04	01	H2228_814_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2228	815	0	1	04	01	H2228_815_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2228	815	0	1	04	01	H2228_815_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2228	816	0	1	04	01	H2228_816_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2228	816	0	1	04	01	H2228_816_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2228	817	0	2	04	01	H2228_817_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2228	817	0	2	04	01	H2228_817_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2228	818	0	2	04	01	H2228_818_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2228	818	0	2	04	01	H2228_818_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2228	819	0	2	04	01	H2228_819_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2228	819	0	2	04	01	H2228_819_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2228	820	0	1	04	01	H2228_820_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2228	820	0	1	04	01	H2228_820_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2228	821	0	1	04	01	H2228_821_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2228	821	0	1	04	01	H2228_821_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2228	822	0	1	04	01	H2228_822_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2228	822	0	1	04	01	H2228_822_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2228	823	0	1	04	01	H2228_823_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2228	823	0	1	04	01	H2228_823_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2228	824	0	1	04	01	H2228_824_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2228	824	0	1	04	01	H2228_824_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2228	825	0	1	04	01	H2228_825_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2228	825	0	1	04	01	H2228_825_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2228	826	0	1	04	01	H2228_826_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2228	826	0	1	04	01	H2228_826_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2228	827	0	1	04	01	H2228_827_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2228	827	0	1	04	01	H2228_827_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2228	828	0	1	04	01	H2228_828_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2228	828	0	1	04	01	H2228_828_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2230	002	0	1	04	01	H2230_002_0	8	1		11	3-1;3-2;3-3;5;6;7c;7e;7h;7i;8a1;8a2;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;	9d;15;	2		1	20	20	2			2	
H2230	002	0	1	04	01	H2230_002_0	8	10		01	15;		2		1	10	10	2			2	
H2230	002	0	1	04	01	H2230_002_0	8	2		11	7a;7b;7d;7f;7g;17a;18a;	14b;16a;17a;18a;	2		2			1	45.00	45.00	2	
H2230	002	0	1	04	01	H2230_002_0	8	3		01	10a;		2		2			1	100.00	100.00	2	
H2230	002	0	1	04	01	H2230_002_0	8	4		01	17b;		2		2			1	0.00	0.00	2	
H2230	002	0	1	04	01	H2230_002_0	8	5		01	14a;14e;16b;		2		1	20	20	1	45.00	45.00	2	
H2230	002	0	1	04	01	H2230_002_0	8	6		01	12;		2		1	0	20	2			2	
H2230	002	0	1	04	01	H2230_002_0	8	7		10		14c;	1	500.00	2			2			2	
H2230	002	0	1	04	01	H2230_002_0	8	8		10		17b;18b;	2		2			2			2	
H2230	002	0	1	04	01	H2230_002_0	8	9		01	8b1;		2		1	40	40	2			2	
H2230	017	0	1	04	01	H2230_017_0	7	1		01	11a;11b;12;15;		2		1	20	20	2			2	
H2230	017	0	1	04	01	H2230_017_0	7	10	Group #10	11	8b2;	16a;	2		2			1	60.00	60.00	2	
H2230	017	0	1	04	01	H2230_017_0	7	11	Group #11	01	5;		2		2			1	55.00	55.00	2	
H2230	017	0	1	04	01	H2230_017_0	7	12	Group #12	01	3-3;8a1;8a2;8b3;		2		2			1	30.00	30.00	2	
H2230	017	0	1	04	01	H2230_017_0	7	13	Group #13	01	7f;7g;18a;		2		2			1	25.00	45.00	2	
H2230	017	0	1	04	01	H2230_017_0	7	14	Group #14	01	7b;		2		2			1	20.00	20.00	2	
H2230	017	0	1	04	01	H2230_017_0	7	15	Group #15	01	8b1;		2		2			1	325.00	325.00	2	
H2230	017	0	1	04	01	H2230_017_0	7	2		11	6;9d;11c;14a;14d;14e;17b;	9d;14b;15;	2		2			1	0.00	0.00	2	
H2230	017	0	1	04	01	H2230_017_0	7	3		01	3-1;3-2;7d;16b;		2		2			1	45.00	45.00	2	
H2230	017	0	1	04	01	H2230_017_0	7	4	Group #4	01	7c;7e;7h;7i;9c;		2		2			1	40.00	40.00	2	
H2230	017	0	1	04	01	H2230_017_0	7	5	Group #5	01	10a;		2		2			1	250.00	250.00	2	
H2230	017	0	1	04	01	H2230_017_0	7	6		10		14c;	1	500.00	2			2			2	
H2230	017	0	1	04	01	H2230_017_0	7	7	Group #7	01	7a;		2		2			1	25.00	25.00	2	
H2230	017	0	1	04	01	H2230_017_0	7	8	Group #8	01	9a;9b;		2		2			1	300.00	300.00	2	
H2230	017	0	1	04	01	H2230_017_0	7	9	Group #9	01	17a;		2		2			1	45.00	45.00	2	
H2230	018	1	1	04	01	H2230_018_1	7	1	Group #1	01	3-1;3-2;3-3;7a;7b;7c;7i;8a1;8a2;8b3;		2		2			1	20.00	20.00	2	
H2230	018	1	1	04	01	H2230_018_1	7	10	Group #10	01	8b1;		2		2			1	250.00	250.00	2	
H2230	018	1	1	04	01	H2230_018_1	7	11	Group #11	01	14e;		2		2			1	0.00	0.00	2	
H2230	018	1	1	04	01	H2230_018_1	7	12	Group #12	01	5;		2		2			1	55.00	55.00	2	
H2230	018	1	1	04	01	H2230_018_1	7	13	Group #13	10		14c;	1	500.00	2			2			2	
H2230	018	1	1	04	01	H2230_018_1	7	14	Group #14	10		17b;	2		2			2			2	
H2230	018	1	1	04	01	H2230_018_1	7	2	Group #2	11	6;8b2;9d;11c;12;14a;14d;17b;	9d;14b;15;	2		2			1	0.00	0.00	2	
H2230	018	1	1	04	01	H2230_018_1	7	3	Group #3	11	7f;7g;18a;	18a;	2		2			1	20.00	40.00	2	
H2230	018	1	1	04	01	H2230_018_1	7	4	Group #4	11	7d;7e;7h;9c;16b;	16a;17a;	2		2			1	40.00	40.00	2	
H2230	018	1	1	04	01	H2230_018_1	7	5	Group #5	01	17a;		2		2			1	40.00	40.00	2	
H2230	018	1	1	04	01	H2230_018_1	7	6	Group #6	01	10a;		2		2			1	100.00	100.00	2	
H2230	018	1	1	04	01	H2230_018_1	7	7	Group #7	01	11a;11b;		2		1	20	20	2			2	
H2230	018	1	1	04	01	H2230_018_1	7	8	Group #8	01	15;		2		1	15	15	2			2	
H2230	018	1	1	04	01	H2230_018_1	7	9	Group #9	01	9a;9b;		2		2			1	225.00	225.00	2	
H2230	018	2	1	04	01	H2230_018_2	7	1	Group #1	01	3-1;3-2;3-3;7a;7b;7c;7i;8a1;8a2;8b3;		2		2			1	20.00	20.00	2	
H2230	018	2	1	04	01	H2230_018_2	7	10	Group #10	01	8b1;		2		2			1	250.00	250.00	2	
H2230	018	2	1	04	01	H2230_018_2	7	11	Group #11	01	14e;		2		2			1	0.00	0.00	2	
H2230	018	2	1	04	01	H2230_018_2	7	12	Group #12	01	5;		2		2			1	55.00	55.00	2	
H2230	018	2	1	04	01	H2230_018_2	7	13	Group #13	10		14c;	1	500.00	2			2			2	
H2230	018	2	1	04	01	H2230_018_2	7	14	Group #14	10		17b;	2		2			2			2	
H2230	018	2	1	04	01	H2230_018_2	7	2	Group #2	11	6;8b2;9d;11c;12;14a;14d;17b;	9d;14b;15;	2		2			1	0.00	0.00	2	
H2230	018	2	1	04	01	H2230_018_2	7	3	Group #3	11	7f;7g;18a;	18a;	2		2			1	20.00	40.00	2	
H2230	018	2	1	04	01	H2230_018_2	7	4	Group #4	11	7d;7e;7h;9c;16b;	16a;17a;	2		2			1	40.00	40.00	2	
H2230	018	2	1	04	01	H2230_018_2	7	5	Group #5	01	17a;		2		2			1	40.00	40.00	2	
H2230	018	2	1	04	01	H2230_018_2	7	6	Group #6	01	10a;		2		2			1	100.00	100.00	2	
H2230	018	2	1	04	01	H2230_018_2	7	7	Group #7	01	11a;11b;		2		1	20	20	2			2	
H2230	018	2	1	04	01	H2230_018_2	7	8	Group #8	01	15;		2		1	15	15	2			2	
H2230	018	2	1	04	01	H2230_018_2	7	9	Group #9	01	9a;9b;		2		2			1	225.00	225.00	2	
H2230	801	0	1	04	01	H2230_801_0	5	1		01	6;14a;		2		1	0	0	2			2	
H2230	801	0	1	04	01	H2230_801_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2230	809	0	1	04	01	H2230_809_0	5	1		01	6;14a;		2		1	0	0	2			2	
H2230	809	0	1	04	01	H2230_809_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2322	004	0	1	04	01	H2322_004_0	9	1	OON Medicare Covered & Enhanced Group 1	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;10a;11c;12;14a;14d;14e;15;16b;17a;18a;	9d;17a;18a;	2		1	20	20	2			2	
H2322	004	0	1	04	01	H2322_004_0	9	2	OON Medicare Covered Grp 2	01	5;7e;7h;9c;11a;11b;		2		1	50	50	2			2	
H2322	004	0	1	04	01	H2322_004_0	9	3	OON Enhanced Group 3	10		14c;	2		2			1	0.00	50.00	2	
H2322	004	0	1	04	01	H2322_004_0	9	4	Enhanced Group 4	11	17b;	17b;	2		1	50	50	2			2	
H2322	008	0	1	04	01	H2322_008_0	9	1	OON Medicare Covered & Enhanced Group 1	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;10a;11c;12;14a;14d;14e;15;16b;17a;18a;	9d;17a;18a;	2		1	25	25	2			2	
H2322	008	0	1	04	01	H2322_008_0	9	2	OON Medicare Covered Grp 2	01	5;7e;7h;9c;11a;11b;		2		1	50	50	2			2	
H2322	008	0	1	04	01	H2322_008_0	9	3	OON Enhanced Group 3	10		14c;	2		2			1	0.00	25.00	2	
H2322	008	0	1	04	01	H2322_008_0	9	4	Enhanced Group 4	11	17b;	17b;	2		1	50	50	2			2	
H2322	011	0	1	04	01	H2322_011_0	9	1	OON Medicare Covered & Enhanced Group 1	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;10a;11c;12;14a;14d;14e;15;16b;17a;18a;	9d;17a;18a;	2		1	30	30	2			2	
H2322	011	0	1	04	01	H2322_011_0	9	2	OON Medicare Covered Grp 2	01	5;7e;7h;9c;11a;11b;		2		1	50	50	2			2	
H2322	011	0	1	04	01	H2322_011_0	9	3	OON Enhanced Group 3	10		14c;	2		2			1	0.00	25.00	2	
H2322	011	0	1	04	01	H2322_011_0	9	4	Enhanced Group 4	11	17b;	17b;	2		1	50	50	2			2	
H2322	801	0	1	04	01	H2322_801_0	4	1		01	6;14a;		2		1	0	0	2			2	
H2322	801	0	1	04	01	H2322_801_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2322	803	0	1	04	01	H2322_803_0	4	1		01	6;14a;		2		1	0	0	2			2	
H2322	803	0	1	04	01	H2322_803_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2322	809	0	1	04	01	H2322_809_0	4	1		01	6;14a;		2		1	0	0	2			2	
H2322	809	0	1	04	01	H2322_809_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2334	001	0	1	04	01	H2334_001_0	9	1	Ambulance	01	10a;		2		2			1	225.00	225.00	2	
H2334	001	0	1	04	01	H2334_001_0	9	2	Preventive Services	01	14a;		2		2			2			2	
H2334	001	0	1	04	01	H2334_001_0	9	3	All Others	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;	7f;	2		1	40	40	2			2	
H2334	001	0	1	04	01	H2334_001_0	9	4	Supplemental Benefits	10		7b;9d;14c;16a;17a;18a;	2		1	50	50	2			2	
H2334	001	0	1	04	01	H2334_001_0	9	5	OTC	10		13b;	1	20.00	1	50	50	2			2	
H2334	001	0	1	04	01	H2334_001_0	9	6		10		17b;	2		1	50	50	2			2	
H2334	001	0	1	04	01	H2334_001_0	9	7	Eyewear	10		18b;	1	750.00	1	50	50	2			2	
H2334	003	0	1	04	01	H2334_003_0	9	1	Ambulance	01	10a;		2		2			1	225.00	225.00	2	
H2334	003	0	1	04	01	H2334_003_0	9	2	Preventive Services	01	14a;		2		2			2			2	
H2334	003	0	1	04	01	H2334_003_0	9	3	All Others	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	40	40	2			2	
H2334	003	0	1	04	01	H2334_003_0	9	4	Supplemental Benefits	10		7b;9d;14c;16a;17a;18a;	2		1	50	50	2			2	
H2334	003	0	1	04	01	H2334_003_0	9	5	OTC	10		13b;	1	20.00	1	50	50	2			2	
H2334	003	0	1	04	01	H2334_003_0	9	6		10		17b;	2		1	50	50	2			2	
H2334	003	0	1	04	01	H2334_003_0	9	7	Eyewear	10		18b;	1	750.00	1	50	50	2			2	
H2406	001	0	1	04	01	H2406_001_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;	2		1	30	30	2			2	
H2406	001	0	1	04	01	H2406_001_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;	2		2			1	0.00	0.00	2	
H2406	001	0	1	04	01	H2406_001_0	4	3	Group 3	01	10a;12;		2		1	20	20	2			2	
H2406	001	0	1	04	01	H2406_001_0	4	4	Group 4	10		10b;	2		1	75	75	2			2	
H2406	001	0	1	04	01	H2406_001_0	4	5	Group 5	01	14a;		2		1	0	30	2			2	
H2406	001	0	1	04	01	H2406_001_0	4	6	Group 6	10		13b;	1	265.00	2			1	0.00	0.00	2	
H2406	008	0	1	04	01	H2406_008_0	4	1	Group 1	01	7a;		2		2			1	45.00	45.00	2	
H2406	008	0	1	04	01	H2406_008_0	4	10	Group 10	11	8a2;9d;	9d;14c;	2		2			1	0.00	0.00	2	
H2406	008	0	1	04	01	H2406_008_0	4	11	Group 11	01	6;11a;15;		2		1	50	50	2			2	
H2406	008	0	1	04	01	H2406_008_0	4	12	Group 12	01	14a;		2		1	0	40	2			2	
H2406	008	0	1	04	01	H2406_008_0	4	13	Group 13	01	7g;		2		2			1	45.00	70.00	2	
H2406	008	0	1	04	01	H2406_008_0	4	14	Group 14	10		16a;	2		2			1	40.00	40.00	2	
H2406	008	0	1	04	01	H2406_008_0	4	15	Group 15	01	14e;		2		1	40	40	1	70.00	70.00	2	
H2406	008	0	1	04	01	H2406_008_0	4	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	70.00	70.00	2	
H2406	008	0	1	04	01	H2406_008_0	4	3	Group 3	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;11b;11c;14d;16b;17b;	14b;	2		1	40	40	2			2	
H2406	008	0	1	04	01	H2406_008_0	4	4	Group 4	01	8b3;		2		2			1	7.00	7.00	2	
H2406	008	0	1	04	01	H2406_008_0	4	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
H2406	008	0	1	04	01	H2406_008_0	4	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H2406	008	0	1	04	01	H2406_008_0	4	7	Group 7	01	10a;		2		2			1	195.00	195.00	2	
H2406	008	0	1	04	01	H2406_008_0	4	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H2406	008	0	1	04	01	H2406_008_0	4	9	Group 9	01	12;		2		1	20	20	2			2	
H2406	009	0	1	04	01	H2406_009_0	4	1	Group 1	01	8a2;		2		2			1	2.00	2.00	2	
H2406	009	0	1	04	01	H2406_009_0	4	10	Group 10	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
H2406	009	0	1	04	01	H2406_009_0	4	11	Group 11	01	6;11a;15;		2		1	50	50	2			2	
H2406	009	0	1	04	01	H2406_009_0	4	12	Group 12	01	14a;		2		1	0	40	2			2	
H2406	009	0	1	04	01	H2406_009_0	4	13	Group 13	01	7a;7g;		2		2			1	45.00	70.00	2	
H2406	009	0	1	04	01	H2406_009_0	4	14	Group 14	10		16a;	2		2			1	40.00	40.00	2	
H2406	009	0	1	04	01	H2406_009_0	4	15	Group 15	01	14e;		2		1	40	40	1	70.00	70.00	2	
H2406	009	0	1	04	01	H2406_009_0	4	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	70.00	70.00	2	
H2406	009	0	1	04	01	H2406_009_0	4	3	Group 3	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;11b;11c;14d;16b;17b;	14b;	2		1	40	40	2			2	
H2406	009	0	1	04	01	H2406_009_0	4	4	Group 4	01	8b3;		2		2			1	21.00	21.00	2	
H2406	009	0	1	04	01	H2406_009_0	4	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
H2406	009	0	1	04	01	H2406_009_0	4	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H2406	009	0	1	04	01	H2406_009_0	4	7	Group 7	01	10a;		2		2			1	250.00	250.00	2	
H2406	009	0	1	04	01	H2406_009_0	4	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H2406	009	0	1	04	01	H2406_009_0	4	9	Group 9	01	12;		2		1	20	20	2			2	
H2406	010	0	1	04	01	H2406_010_0	4	1	Group 1	01	8a2;		2		2			1	3.00	3.00	2	
H2406	010	0	1	04	01	H2406_010_0	4	10	Group 10	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
H2406	010	0	1	04	01	H2406_010_0	4	11	Group 11	01	6;11a;15;		2		1	50	50	2			2	
H2406	010	0	1	04	01	H2406_010_0	4	12	Group 12	01	14a;		2		1	0	40	2			2	
H2406	010	0	1	04	01	H2406_010_0	4	13	Group 13	01	7a;7g;		2		2			1	45.00	70.00	2	
H2406	010	0	1	04	01	H2406_010_0	4	14	Group 14	10		16a;	2		2			1	40.00	40.00	2	
H2406	010	0	1	04	01	H2406_010_0	4	15	Group 15	01	14e;		2		1	40	40	1	70.00	70.00	2	
H2406	010	0	1	04	01	H2406_010_0	4	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	70.00	70.00	2	
H2406	010	0	1	04	01	H2406_010_0	4	3	Group 3	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;11b;11c;14d;16b;17b;	14b;	2		1	40	40	2			2	
H2406	010	0	1	04	01	H2406_010_0	4	4	Group 4	01	8b3;		2		2			1	21.00	21.00	2	
H2406	010	0	1	04	01	H2406_010_0	4	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
H2406	010	0	1	04	01	H2406_010_0	4	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H2406	010	0	1	04	01	H2406_010_0	4	7	Group 7	01	10a;		2		2			1	250.00	250.00	2	
H2406	010	0	1	04	01	H2406_010_0	4	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H2406	010	0	1	04	01	H2406_010_0	4	9	Group 9	01	12;		2		1	20	20	2			2	
H2406	011	0	1	04	01	H2406_011_0	4	1	Group 1	01	7a;		2		2			1	45.00	45.00	2	
H2406	011	0	1	04	01	H2406_011_0	4	10	Group 10	11	8a2;9d;	9d;14c;	2		2			1	0.00	0.00	2	
H2406	011	0	1	04	01	H2406_011_0	4	11	Group 11	01	6;11a;15;		2		1	50	50	2			2	
H2406	011	0	1	04	01	H2406_011_0	4	12	Group 12	01	14a;		2		1	0	40	2			2	
H2406	011	0	1	04	01	H2406_011_0	4	13	Group 13	01	7g;		2		2			1	45.00	70.00	2	
H2406	011	0	1	04	01	H2406_011_0	4	14	Group 14	10		16a;	2		2			1	40.00	40.00	2	
H2406	011	0	1	04	01	H2406_011_0	4	15	Group 15	01	14e;		2		1	40	40	1	70.00	70.00	2	
H2406	011	0	1	04	01	H2406_011_0	4	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	70.00	70.00	2	
H2406	011	0	1	04	01	H2406_011_0	4	3	Group 3	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;11b;11c;14d;16b;17b;	14b;	2		1	40	40	2			2	
H2406	011	0	1	04	01	H2406_011_0	4	4	Group 4	01	8b3;		2		2			1	7.00	7.00	2	
H2406	011	0	1	04	01	H2406_011_0	4	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
H2406	011	0	1	04	01	H2406_011_0	4	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H2406	011	0	1	04	01	H2406_011_0	4	7	Group 7	01	10a;		2		2			1	185.00	185.00	2	
H2406	011	0	1	04	01	H2406_011_0	4	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H2406	011	0	1	04	01	H2406_011_0	4	9	Group 9	01	12;		2		1	20	20	2			2	
H2406	805	0	1	04	01	H2406_805_0	3	1		01	6;14a;		2		1	0	0	2			2	
H2406	805	0	1	04	01	H2406_805_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2406	806	0	1	04	01	H2406_806_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2406	806	0	1	04	01	H2406_806_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2406	807	0	1	04	01	H2406_807_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2406	807	0	1	04	01	H2406_807_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2406	808	0	2	04	01	H2406_808_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2406	808	0	2	04	01	H2406_808_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2406	809	0	2	04	01	H2406_809_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2406	809	0	2	04	01	H2406_809_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2406	810	0	2	04	01	H2406_810_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2406	810	0	2	04	01	H2406_810_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2406	811	0	1	04	01	H2406_811_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2406	811	0	1	04	01	H2406_811_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2406	812	0	1	04	01	H2406_812_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2406	812	0	1	04	01	H2406_812_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2406	813	0	1	04	01	H2406_813_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2406	813	0	1	04	01	H2406_813_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2406	814	0	1	04	01	H2406_814_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2406	814	0	1	04	01	H2406_814_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2406	815	0	1	04	01	H2406_815_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2406	815	0	1	04	01	H2406_815_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2406	816	0	2	04	01	H2406_816_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2406	816	0	2	04	01	H2406_816_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2406	817	0	2	04	01	H2406_817_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2406	817	0	2	04	01	H2406_817_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2406	818	0	2	04	01	H2406_818_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2406	818	0	2	04	01	H2406_818_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2406	819	0	1	04	01	H2406_819_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2406	819	0	1	04	01	H2406_819_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2406	820	0	1	04	01	H2406_820_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2406	820	0	1	04	01	H2406_820_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2406	821	0	1	04	01	H2406_821_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2406	821	0	1	04	01	H2406_821_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2406	822	0	1	04	01	H2406_822_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2406	822	0	1	04	01	H2406_822_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2406	823	0	1	04	01	H2406_823_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2406	823	0	1	04	01	H2406_823_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2406	824	0	1	04	01	H2406_824_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2406	824	0	1	04	01	H2406_824_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2406	825	0	1	04	01	H2406_825_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2406	825	0	1	04	01	H2406_825_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2406	826	0	1	04	01	H2406_826_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2406	826	0	1	04	01	H2406_826_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2406	827	0	1	04	01	H2406_827_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2406	827	0	1	04	01	H2406_827_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2486	003	0	1	01	01	H2486_003_0	6	1														
H2591	801	0	1	04	01	H2591_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2591	801	0	1	04	01	H2591_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2591	802	0	1	04	01	H2591_802_0	2	1		01	6;14a;		2		1	0	0	2			2	
H2591	802	0	1	04	01	H2591_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2591	803	0	1	04	01	H2591_803_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2591	803	0	1	04	01	H2591_803_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2649	012	0	1	01	01	H2649_012_0	2	1														
H2649	021	0	1	01	01	H2649_021_0	3	1														
H2649	023	0	1	01	01	H2649_023_0	6	1														
H2649	028	0	1	01	01	H2649_028_0	3	1														
H2649	029	0	1	01	01	H2649_029_0	4	1														
H2649	030	0	1	01	01	H2649_030_0	5	1														
H2649	031	0	1	01	01	H2649_031_0	4	1														
H2649	032	0	1	01	01	H2649_032_0	4	1														
H2649	033	0	1	01	01	H2649_033_0	4	1														
H2649	034	0	1	01	01	H2649_034_0	4	1														
H2649	039	0	1	01	01	H2649_039_0	4	1														
H2649	043	0	1	01	01	H2649_043_0	4	1														
H2649	045	0	1	01	01	H2649_045_0	3	1														
H2649	046	0	1	01	01	H2649_046_0	5	1														
H2649	048	0	1	01	01	H2649_048_0	4	1														
H2649	049	0	1	01	01	H2649_049_0	4	1														
H2649	050	0	1	01	01	H2649_050_0	4	1														
H2649	051	0	1	01	01	H2649_051_0	2	1														
H2649	052	0	1	01	01	H2649_052_0	2	1														
H2649	053	0	1	01	01	H2649_053_0	2	1														
H2649	054	0	1	01	01	H2649_054_0	2	1														
H2649	055	0	1	01	01	H2649_055_0	2	1														
H2649	056	0	1	02	01	H2649_056_0	3	1														
H2649	056	0	1	02	01	H2649_056_0	3	2														
H2649	056	0	1	02	01	H2649_056_0	3	3														
H2649	059	1	1	01	01	H2649_059_1	4	1														
H2649	059	2	1	01	01	H2649_059_2	3	1														
H2649	060	0	1	02	01	H2649_060_0	4	1														
H2649	060	0	1	02	01	H2649_060_0	4	2														
H2649	060	0	1	02	01	H2649_060_0	4	3														
H2649	061	1	1	01	01	H2649_061_1	3	1														
H2649	061	2	1	01	01	H2649_061_2	3	1														
H2649	062	1	1	01	01	H2649_062_1	3	1														
H2649	062	2	1	01	01	H2649_062_2	3	1														
H2649	063	0	1	01	01	H2649_063_0	3	1														
H2649	064	0	1	01	01	H2649_064_0	2	1														
H2649	065	1	1	01	01	H2649_065_1	2	1														
H2649	065	2	1	01	01	H2649_065_2	2	1														
H2649	066	0	1	01	01	H2649_066_0	6	1														
H2649	067	0	1	01	01	H2649_067_0	2	1														
H2775	082	0	1	04	01	H2775_082_0	8	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;17a;17b;18a;	9d;14c;16a;16b;17a;18a;	2		1	30	30	2			2	
H2775	082	0	1	04	01	H2775_082_0	8	2		01	7b;		2		1	30	30	2			2	
H2775	082	0	1	04	01	H2775_082_0	8	3		11	7a;7g;	14b;	2		2			1	10.00	10.00	2	
H2775	082	0	1	04	01	H2775_082_0	8	4		01	7d;16b;		2		2			1	35.00	35.00	2	
H2775	082	0	1	04	01	H2775_082_0	8	5		01	10a;		2		2			1	300.00	300.00	2	
H2775	083	0	1	04	01	H2775_083_0	11	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;17a;17b;18a;	9d;14c;16a;16b;17a;18a;	2		1	30	30	2			2	
H2775	083	0	1	04	01	H2775_083_0	11	2		01	7b;		2		1	30	30	2			2	
H2775	083	0	1	04	01	H2775_083_0	11	3		11	7a;7g;	14b;	2		2			1	10.00	10.00	2	
H2775	083	0	1	04	01	H2775_083_0	11	4		01	7d;16b;		2		2			1	35.00	35.00	2	
H2775	083	0	1	04	01	H2775_083_0	11	5		01	10a;		2		2			1	300.00	300.00	2	
H2775	088	0	1	04	01	H2775_088_0	8	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;17a;17b;18a;	9d;14c;16a;16b;17a;18a;	2		1	30	30	2			2	
H2775	088	0	1	04	01	H2775_088_0	8	2		01	7b;		2		1	30	30	2			2	
H2775	088	0	1	04	01	H2775_088_0	8	3		11	7a;7g;	14b;	2		2			1	25.00	25.00	2	
H2775	088	0	1	04	01	H2775_088_0	8	4		01	7d;16b;		2		2			1	60.00	60.00	2	
H2775	088	0	1	04	01	H2775_088_0	8	5		01	10a;		2		2			1	300.00	300.00	2	
H2775	089	0	1	04	01	H2775_089_0	8	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;17a;17b;18a;	9d;14c;16a;16b;17a;18a;	2		1	30	30	2			2	
H2775	089	0	1	04	01	H2775_089_0	8	2		01	7b;		2		1	30	30	2			2	
H2775	089	0	1	04	01	H2775_089_0	8	3		11	7a;7g;	14b;	2		2			1	25.00	25.00	2	
H2775	089	0	1	04	01	H2775_089_0	8	4		01	7d;16b;		2		2			1	60.00	60.00	2	
H2775	089	0	1	04	01	H2775_089_0	8	5		01	10a;		2		2			1	300.00	300.00	2	
H2775	095	0	1	04	01	H2775_095_0	7	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;17a;17b;18a;	9d;14c;17a;18a;	2		1	30	30	2			2	
H2775	095	0	1	04	01	H2775_095_0	7	2		01	7b;		2		1	30	30	2			2	
H2775	095	0	1	04	01	H2775_095_0	7	3		11	7a;7g;	14b;	2		2			1	15.00	15.00	2	
H2775	095	0	1	04	01	H2775_095_0	7	4		01	7d;16b;		2		2			1	50.00	50.00	2	
H2775	095	0	1	04	01	H2775_095_0	7	5		01	10a;		2		2			1	300.00	300.00	2	
H2775	099	0	1	04	01	H2775_099_0	8	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;17a;17b;18a;	9d;14c;16a;16b;17a;18a;	2		1	30	30	2			2	
H2775	099	0	1	04	01	H2775_099_0	8	2		01	7b;		2		1	30	30	2			2	
H2775	099	0	1	04	01	H2775_099_0	8	3		11	7a;7g;	14b;	2		2			1	20.00	20.00	2	
H2775	099	0	1	04	01	H2775_099_0	8	4		01	7d;16b;		2		2			1	50.00	50.00	2	
H2775	099	0	1	04	01	H2775_099_0	8	5		01	10a;		2		2			1	300.00	300.00	2	
H2775	100	0	1	04	01	H2775_100_0	8	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;17a;17b;18a;	9d;14c;16a;16b;17a;18a;	2		1	30	30	2			2	
H2775	100	0	1	04	01	H2775_100_0	8	2		01	7b;		2		1	30	30	2			2	
H2775	100	0	1	04	01	H2775_100_0	8	3		11	7a;7g;	14b;	2		2			1	30.00	30.00	2	
H2775	100	0	1	04	01	H2775_100_0	8	4		01	7d;16b;		2		2			1	60.00	60.00	2	
H2775	100	0	1	04	01	H2775_100_0	8	5		01	10a;		2		2			1	300.00	300.00	2	
H2775	801	0	1	04	01	H2775_801_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2775	801	0	1	04	01	H2775_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2775	802	0	1	04	01	H2775_802_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2775	802	0	1	04	01	H2775_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2775	803	0	1	04	01	H2775_803_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2775	803	0	1	04	01	H2775_803_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2816	001	0	1	09	04	H2816_001_0	7	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;17a;17b;18a;	9d;14c;17a;18a;	2		1	30	30	2			2	
H2816	001	0	1	09	04	H2816_001_0	7	2		01	7b;				1	30	30	2			2	
H2816	001	0	1	09	04	H2816_001_0	7	3		11	7a;7g;	14b;	2		2			1	10.00	10.00	2	
H2816	001	0	1	09	04	H2816_001_0	7	4		01	7d;16b;				2			1	35.00	35.00	2	
H2816	001	0	1	09	04	H2816_001_0	7	5		01	10a;				2			1	300.00	300.00	2	
H2816	002	0	1	09	04	H2816_002_0	7	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;17a;17b;18a;	9d;14c;17a;18a;	2		1	30	30	2			2	
H2816	002	0	1	09	04	H2816_002_0	7	2		01	7b;				1	30	30	2			2	
H2816	002	0	1	09	04	H2816_002_0	7	3		11	7a;7g;	14b;	2		2			1	10.00	10.00	2	
H2816	002	0	1	09	04	H2816_002_0	7	4		01	7d;16b;				2			1	35.00	35.00	2	
H2816	002	0	1	09	04	H2816_002_0	7	5		01	10a;				2			1	300.00	300.00	2	
H2816	007	0	1	09	04	H2816_007_0	7	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;17a;17b;18a;	9d;14c;17a;18a;	2		1	30	30	2			2	
H2816	007	0	1	09	04	H2816_007_0	7	2		01	7b;				1	30	30	2			2	
H2816	007	0	1	09	04	H2816_007_0	7	3		11	7a;7g;	14b;	2		2			1	15.00	15.00	2	
H2816	007	0	1	09	04	H2816_007_0	7	4		01	7d;16b;				2			1	50.00	50.00	2	
H2816	007	0	1	09	04	H2816_007_0	7	5		01	10a;				2			1	300.00	300.00	2	
H2816	008	0	1	09	04	H2816_008_0	7	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;17a;17b;18a;	9d;14c;17a;18a;	2		1	30	30	2			2	
H2816	008	0	1	09	04	H2816_008_0	7	2		01	7b;				1	30	30	2			2	
H2816	008	0	1	09	04	H2816_008_0	7	3		11	7a;7g;	14b;	2		2			1	15.00	15.00	2	
H2816	008	0	1	09	04	H2816_008_0	7	4		01	7d;16b;				2			1	50.00	50.00	2	
H2816	008	0	1	09	04	H2816_008_0	7	5		01	10a;				2			1	300.00	300.00	2	
H2816	013	0	1	09	04	H2816_013_0	11	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;17a;17b;18a;	9d;14c;17a;18a;	2		1	30	30	2			2	
H2816	013	0	1	09	04	H2816_013_0	11	2		01	7b;				1	30	30	2			2	
H2816	013	0	1	09	04	H2816_013_0	11	3		11	7a;7g;	14b;	2		2			1	10.00	10.00	2	
H2816	013	0	1	09	04	H2816_013_0	11	4		01	7d;16b;				2			1	35.00	35.00	2	
H2816	013	0	1	09	04	H2816_013_0	11	5		01	10a;				2			1	300.00	300.00	2	
H2816	019	0	1	09	04	H2816_019_0	8	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;17a;17b;18a;	9d;14c;17a;18a;	2		1	30	30	2			2	
H2816	019	0	1	09	04	H2816_019_0	8	2		01	7b;				1	30	30	2			2	
H2816	019	0	1	09	04	H2816_019_0	8	3		11	7a;7g;	14b;	2		2			1	25.00	25.00	2	
H2816	019	0	1	09	04	H2816_019_0	8	4		01	7d;16b;				2			1	60.00	60.00	2	
H2816	019	0	1	09	04	H2816_019_0	8	5		01	10a;				2			1	300.00	300.00	2	
H2816	801	0	1	09	04	H2816_801_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2816	801	0	1	09	04	H2816_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2816	802	0	1	09	04	H2816_802_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2816	802	0	1	09	04	H2816_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2816	803	0	1	09	04	H2816_803_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2816	803	0	1	09	04	H2816_803_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2836	801	0	1	04	01	H2836_801_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2836	801	0	1	04	01	H2836_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2836	802	0	1	04	01	H2836_802_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2836	802	0	1	04	01	H2836_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2836	803	0	1	04	01	H2836_803_0	1	1		01	6;14a;		2		1	0	0	2			2	
H2836	803	0	1	04	01	H2836_803_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2906	005	0	1	04	01	H2906_005_0	12	1	Out-of-Network (OON) Services	11	3-1;3-2;3-3;5;6;7c;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	16a;18a;18b;	2		1	30	30	2			2	
H2906	005	0	1	04	01	H2906_005_0	12	10	OON Eye Exam	10		17a;	2		2			1	25.00	25.00	2	
H2906	005	0	1	04	01	H2906_005_0	12	2	Primary Care Physician Services	01	7a;		2		2			1	25.00	25.00	2	
H2906	005	0	1	04	01	H2906_005_0	12	3	Physician Specialist Services	01	7d;7e;7f;7g;7h;		2		2			1	65.00	65.00	2	
H2906	005	0	1	04	01	H2906_005_0	12	4	Outpatient Blood Servoces	10		9d;	2		1	30	30	2			2	
H2906	005	0	1	04	01	H2906_005_0	12	5	Supplemental Education/Wellness Programs	10		14c;	2		2			2			2	
H2906	005	0	1	04	01	H2906_005_0	12	6	OON Transportation Services	10		10b;	2		2			2			2	
H2906	005	0	1	04	01	H2906_005_0	12	7	OON Chiropractic Services	01	7b;		2		2			1	40.00	40.00	2	
H2906	005	0	1	04	01	H2906_005_0	12	8	OON Preventive Dental	10		16b;	2		1	30	50	2			1	100.00
H2906	005	0	1	04	01	H2906_005_0	12	9	OON Eyewear	10		17b;	1	150.00	2			2			2	
H2906	006	0	1	04	01	H2906_006_0	10	1	Out-of-Network (OON) Services	11	3-1;3-2;3-3;5;6;7c;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	18a;18b;	2		1	30	30	2			2	
H2906	006	0	1	04	01	H2906_006_0	10	10	OON Routine Eye Exam	10		17a;	2		2			1	45.00	45.00	2	
H2906	006	0	1	04	01	H2906_006_0	10	2	OON Primary Care Physician Services	01	7a;		2		2			1	35.00	35.00	2	
H2906	006	0	1	04	01	H2906_006_0	10	3	OON Physician Specialist Services	01	7d;7e;7f;7g;7h;		2		2			1	65.00	65.00	2	
H2906	006	0	1	04	01	H2906_006_0	10	4	OON Outpatient Blood Services	10		9d;	2		1	30	30	2			2	
H2906	006	0	1	04	01	H2906_006_0	10	5	OON Supp Education/Welness Programs	10		14c;	2		2			2			2	
H2906	006	0	1	04	01	H2906_006_0	10	6	OON Transportation Services	10		10b;	2		2			2			2	
H2906	006	0	1	04	01	H2906_006_0	10	7	OON Chiropractic Services	01	7b;		2		2			1	40.00	40.00	2	
H2906	006	0	1	04	01	H2906_006_0	10	8	OON Preventive Dental	10		16a;	2		1	30	30	2			2	
H2906	006	0	1	04	01	H2906_006_0	10	9	OON Eyewear	10		17b;	2		2			2			2	
H2906	007	0	1	04	01	H2906_007_0	10	1	Out-of-Network (OON) Services	11	3-1;3-2;3-3;5;6;7c;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	18a;18b;	2		1	30	30	2			2	
H2906	007	0	1	04	01	H2906_007_0	10	2	OON Primary Care Physician Services	01	7a;		2		2			1	35.00	35.00	2	
H2906	007	0	1	04	01	H2906_007_0	10	3	OON Physician Specialist Services	01	7d;7e;7f;7g;7h;		2		2			1	75.00	75.00	2	
H2906	007	0	1	04	01	H2906_007_0	10	4	OON Outpatient Blood Services	10		9d;	2		1	30	30	2			2	
H2906	007	0	1	04	01	H2906_007_0	10	5	OON Supp Education/Welness Programs	10		14c;	2		2			2			2	
H2906	007	0	1	04	01	H2906_007_0	10	6	OON Transportation Services	10		10b;	2		2			2			2	
H2906	007	0	1	04	01	H2906_007_0	10	7	OON Chiropractic Services	01	7b;		2		2			1	40.00	40.00	2	
H2906	007	0	1	04	01	H2906_007_0	10	8	OON Routine Eye Exams	10		17a;	2		2			1	45.00	45.00	2	
H2906	007	0	1	04	01	H2906_007_0	10	9	OON Eyewear	10		17b;	2		2			2			2	
H2906	008	0	1	04	01	H2906_008_0	9	1	Out-of-Network (OON) Services	11	3-1;3-2;3-3;5;6;7c;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	18a;18b;	2		1	30	30	2			2	
H2906	008	0	1	04	01	H2906_008_0	9	2	OON Primary Care Physician Services	01	7a;		2		2			1	35.00	35.00	2	
H2906	008	0	1	04	01	H2906_008_0	9	3	OON Physician Specialist Services	01	7d;7e;7f;7g;7h;		2		2			1	75.00	75.00	2	
H2906	008	0	1	04	01	H2906_008_0	9	4	OON Outpatient Blood Services	10		9d;	2		1	30	30	2			2	
H2906	008	0	1	04	01	H2906_008_0	9	5	OON Supp Education/Welness Programs	10		14c;	2		2			1	0.00	0.00	2	
H2906	008	0	1	04	01	H2906_008_0	9	6	OON Transportation Services	10		10b;	2		2			2			2	
H2906	008	0	1	04	01	H2906_008_0	9	7	OON Chiropractic Services	01	7b;		2		2			1	40.00	40.00	2	
H2906	008	0	1	04	01	H2906_008_0	9	8	OON Routine Eye Exams	10		17a;	2		2			1	45.00	45.00	2	
H2906	008	0	1	04	01	H2906_008_0	9	9	OON Eyewear	10		17b;	2		2			2			2	
H2906	801	0	1	04	01	H2906_801_0	4	1		11	6;14a;	17a;17b;	2		1	0	0	2			2	
H2906	801	0	1	04	01	H2906_801_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H2944	004	0	1	09	04	H2944_004_0	3	1		11	9d;14e;	9d;14b;	2		2			1	0.00	0.00	2	
H2944	004	0	1	09	04	H2944_004_0	3	2		01	11a;11c;				1	30	30	2			2	
H2944	004	0	1	09	04	H2944_004_0	3	3		10		13c;14c;	2		1	50	50	2			2	
H2944	013	0	1	09	04	H2944_013_0	3	1		11	8a2;9d;14a;14e;	9d;14b;	2		2			1	0.00	0.00	2	
H2944	013	0	1	09	04	H2944_013_0	3	2		01	11a;				1	15	15	2			2	
H2944	013	0	1	09	04	H2944_013_0	3	3		01	11c;				1	20	20	2			2	
H2944	013	0	1	09	04	H2944_013_0	3	4		10		13c;14c;	2		1	50	50	2			2	
H2944	114	0	1	09	04	H2944_114_0	3	1		11	6;8a2;9d;14a;14e;	9d;14b;	2		2			1	0.00	0.00	2	
H2944	114	0	1	09	04	H2944_114_0	3	2		01	11a;11c;				1	20	20	2			2	
H2944	114	0	1	09	04	H2944_114_0	3	3		10		13c;14c;	2		1	50	50	2			2	
H2944	114	0	1	09	04	H2944_114_0	3	4		10		13b;	1	25.00	1	50	50	2			2	
H2944	124	0	1	09	04	H2944_124_0	5	1		11	8a2;9d;14a;14e;	9d;14b;	2		2			1	0.00	0.00	2	
H2944	124	0	1	09	04	H2944_124_0	5	2		01	11a;11c;				1	20	20	2			2	
H2944	124	0	1	09	04	H2944_124_0	5	3		10		13c;14c;	2		1	50	50	2			2	
H2944	127	0	1	09	04	H2944_127_0	3	1		11	8a2;9d;14a;14e;	9d;14b;	2		2			1	0.00	0.00	2	
H2944	127	0	1	09	04	H2944_127_0	3	2		01	11a;11c;				1	20	20	2			2	
H2944	127	0	1	09	04	H2944_127_0	3	3		10		13c;14c;	2		1	50	50	2			2	
H2944	127	0	1	09	04	H2944_127_0	3	4		10		13b;	1	45.00	1	50	50	2			2	
H2944	197	0	1	09	04	H2944_197_0	2	1		11	8a2;9d;14a;14e;	9d;14b;	2		2			1	0.00	0.00	2	
H2944	197	0	1	09	04	H2944_197_0	2	2		01	11a;				1	19	19	2			2	
H2944	197	0	1	09	04	H2944_197_0	2	3		01	11c;				1	20	20	2			2	
H2944	197	0	1	09	04	H2944_197_0	2	4		10		13c;14c;	2		1	50	50	2			2	
H2968	001	0	1	04	01	H2968_001_0	6	1	OON Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	18a;	2		1	40	40	2			2	
H2968	001	0	1	04	01	H2968_001_0	6	2	OON - ESRD	01	12;		2		1	40	40	2			2	
H2968	001	0	1	04	01	H2968_001_0	6	3	OON - Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H2968	001	0	1	04	01	H2968_001_0	6	4	OON-Hearing Aids	10		18b;	2		2			2			2	
H2968	001	0	1	04	01	H2968_001_0	6	5	OON-Eyewear	10		17b;	2		2			2			2	
H2968	001	0	1	04	01	H2968_001_0	6	6	Eligible Supplemental Benefits	10		14c;	2		2			2			2	
H2968	001	0	1	04	01	H2968_001_0	6	7	OON-Annual Physical	10		14b;	2		2			2			2	
H3206	001	0	1	04	01	H3206_001_0	7	1	0.00	11	6;9d;12;14d;	9d;	2		2			1	0.00	0.00	2	
H3206	001	0	1	04	01	H3206_001_0	7	2	35.00	11	3-1;3-2;3-3;7a;7c;7g;7i;14a;	3-1;3-2;3-3;14b;14c;	2		2			1	35.00	35.00	2	
H3206	001	0	1	04	01	H3206_001_0	7	3	60.00	11	7b;7d;7f;16b;17a;18a;	13a;17a;18a;	2		2			1	60.00	60.00	2	
H3206	001	0	1	04	01	H3206_001_0	7	4	200.00	01	10a;		2		2			1	200.00	200.00	2	
H3206	001	0	1	04	01	H3206_001_0	7	5	20%	01	8a1;8a2;8b1;8b2;8b3;9a;9b;15;		2		1	20	20	2			2	
H3206	001	0	1	04	01	H3206_001_0	7	6	25%	01	11a;11b;11c;14e;17b;		2		1	25	25	2			2	
H3206	001	0	1	04	01	H3206_001_0	7	7	50%	01	5;7e;7h;9c;		2		1	50	50	2			2	
H3206	003	0	1	04	01	H3206_003_0	4	1	0.00	11	6;9d;12;14d;	9d;	2		2			1	0.00	0.00	2	
H3206	003	0	1	04	01	H3206_003_0	4	2	35.00	11	3-1;3-2;3-3;7a;7c;7g;7i;14a;	3-1;3-2;3-3;14b;14c;	2		2			1	35.00	35.00	2	
H3206	003	0	1	04	01	H3206_003_0	4	3	60.00	11	7b;7d;7f;16b;17a;18a;	13a;17a;18a;	2		2			1	60.00	60.00	2	
H3206	003	0	1	04	01	H3206_003_0	4	4	200.00	01	10a;		2		2			1	200.00	200.00	2	
H3206	003	0	1	04	01	H3206_003_0	4	5	20%	01	8a1;8a2;8b1;8b2;8b3;9a;9b;15;		2		1	20	20	2			2	
H3206	003	0	1	04	01	H3206_003_0	4	6	25%	01	11a;11b;11c;14e;17b;		2		1	25	25	2			2	
H3206	003	0	1	04	01	H3206_003_0	4	7	50%	01	5;7e;7h;9c;		2		1	50	50	2			2	
H3206	801	0	1	04	01	H3206_801_0	1	1		01	6;14a;		2		1	0	0	2			2	
H3206	801	0	1	04	01	H3206_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3206	802	0	1	04	01	H3206_802_0	1	1		01	6;14a;		2		1	0	0	2			2	
H3206	802	0	1	04	01	H3206_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3206	803	0	1	04	01	H3206_803_0	1	1		01	6;14a;		2		1	0	0	2			2	
H3206	803	0	1	04	01	H3206_803_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3335	005	0	1	04	01	H3335_005_0	5	1	30% Coinsurance	11	5;6;7e;7h;8a1;8a2;8b1;8b2;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;	9d;14b;	2		1	30	30	2			2	
H3335	005	0	1	04	01	H3335_005_0	5	10	ESRD	01	12;		2		1	20	20	2			2	
H3335	005	0	1	04	01	H3335_005_0	5	11		10		18a;	2		2			1	75.00	75.00	2	
H3335	005	0	1	04	01	H3335_005_0	5	2	Hearing Aid	10		18b;	2		2			2			2	
H3335	005	0	1	04	01	H3335_005_0	5	3	Ambulance	01	10a;		2		2			1	225.00	225.00	2	
H3335	005	0	1	04	01	H3335_005_0	5	4	PT/OT/ST	01	7c;7i;		2		2			1	50.00	50.00	2	
H3335	005	0	1	04	01	H3335_005_0	5	5	Preventive Services	01	14a;		2		1	0	30	2			2	
H3335	005	0	1	04	01	H3335_005_0	5	6	Supplemental Education/Wellness Programs	10		14c;	1	150.00	2			2			2	
H3335	005	0	1	04	01	H3335_005_0	5	7	$25 Copayment	01	7a;7b;		2		2			1	25.00	25.00	2	
H3335	005	0	1	04	01	H3335_005_0	5	8	$55 Copayment - Specialist Services	11	3-1;3-2;3-3;7d;7f;7g;8b3;16b;17a;17b;18a;	17a;	2		2			1	55.00	55.00	2	
H3335	005	0	1	04	01	H3335_005_0	5	9	Preventive Dental & Eyewear	10		16a;17b;	2		2			2			2	
H3335	006	0	1	04	01	H3335_006_0	5	1	30% Coinsurance	11	5;6;7e;7h;8a1;8a2;8b1;8b2;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;	9d;14b;	2		1	30	30	2			2	
H3335	006	0	1	04	01	H3335_006_0	5	10		10		18a;	2		2			1	75.00	75.00	2	
H3335	006	0	1	04	01	H3335_006_0	5	11	Eyewear Allowance	10		17b;	2		2			2			2	
H3335	006	0	1	04	01	H3335_006_0	5	2	Hearing Aid	10		18b;	2		2			2			2	
H3335	006	0	1	04	01	H3335_006_0	5	3	Ambulance	01	10a;		2		2			1	150.00	150.00	2	
H3335	006	0	1	04	01	H3335_006_0	5	4	Specialist	11	3-1;3-2;3-3;7c;7d;7f;7g;7i;8b3;16b;17a;17b;18a;	17a;	2		2			1	50.00	50.00	2	
H3335	006	0	1	04	01	H3335_006_0	5	5	Preventive Services	01	14a;		2		1	0	30	2			2	
H3335	006	0	1	04	01	H3335_006_0	5	6	Supplemental Education/Wellness Programs	10		14c;	1	150.00	2			2			2	
H3335	006	0	1	04	01	H3335_006_0	5	7	$20 Copayment	01	7a;7b;		2		2			1	20.00	20.00	2	
H3335	006	0	1	04	01	H3335_006_0	5	8	Preventive Dental	10		16a;	2		2			2			2	
H3335	006	0	1	04	01	H3335_006_0	5	9	ESRD	01	12;		2		1	20	20	2			2	
H3335	014	0	1	04	01	H3335_014_0	5	1	30% Coinsurance	11	5;6;7e;7h;8a1;8a2;8b1;8b2;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;	9d;14b;	2		1	30	30	2			2	
H3335	014	0	1	04	01	H3335_014_0	5	10	ESRD	01	12;		2		1	20	20	2			2	
H3335	014	0	1	04	01	H3335_014_0	5	11		10		18a;	2		2			1	75.00	75.00	2	
H3335	014	0	1	04	01	H3335_014_0	5	2	Hearing AId	10		18b;	2		2			2			2	
H3335	014	0	1	04	01	H3335_014_0	5	3	Ambulance	01	10a;		2		2			1	225.00	225.00	2	
H3335	014	0	1	04	01	H3335_014_0	5	4	PT/OT/ST	01	7c;7i;		2		2			1	50.00	50.00	2	
H3335	014	0	1	04	01	H3335_014_0	5	5	Preventive Services	01	14a;		2		1	0	30	2			2	
H3335	014	0	1	04	01	H3335_014_0	5	6	Supplemental Education/Wellness Programs	10		14c;	1	150.00	2			2			2	
H3335	014	0	1	04	01	H3335_014_0	5	7	$25 Copayment	01	7a;7b;		2		2			1	25.00	25.00	2	
H3335	014	0	1	04	01	H3335_014_0	5	8	$55 Copayment - Specialist Services	11	3-1;3-2;3-3;7d;7f;7g;8b3;16b;17a;17b;18a;	17a;	2		2			1	55.00	55.00	2	
H3335	014	0	1	04	01	H3335_014_0	5	9	Preventive Dental & Eyewear	10		16a;17b;	2		2			2			2	
H3335	015	0	1	04	01	H3335_015_0	5	1	30% Coinsurance	11	5;6;7e;7h;8a1;8a2;8b1;8b2;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;	9d;14b;	2		1	30	30	2			2	
H3335	015	0	1	04	01	H3335_015_0	5	10		10		18a;	2		2			1	75.00	75.00	2	
H3335	015	0	1	04	01	H3335_015_0	5	11	Eyewear Allowance	10		17b;	2		2			2			2	
H3335	015	0	1	04	01	H3335_015_0	5	2	Hearing Aid	10		18b;	2		2			2			2	
H3335	015	0	1	04	01	H3335_015_0	5	3	Ambulance	01	10a;		2		2			1	150.00	150.00	2	
H3335	015	0	1	04	01	H3335_015_0	5	4	Specialist	11	3-1;3-2;3-3;7c;7d;7f;7g;7i;8b3;16b;17a;17b;18a;	17a;	2		2			1	50.00	50.00	2	
H3335	015	0	1	04	01	H3335_015_0	5	5	Preventive Services	01	14a;		2		1	0	30	2			2	
H3335	015	0	1	04	01	H3335_015_0	5	6	Supplemental Education/Wellness Programs	10		14c;	1	150.00	2			2			2	
H3335	015	0	1	04	01	H3335_015_0	5	7	$20 Copayment	01	7a;7b;		2		2			1	20.00	20.00	2	
H3335	015	0	1	04	01	H3335_015_0	5	8	Preventive Dental	10		16a;	2		2			2			2	
H3335	015	0	1	04	01	H3335_015_0	5	9	ESRD	01	12;		2		1	20	20	2			2	
H3335	018	0	1	04	01	H3335_018_0	5	1	30% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;	2		1	30	30	2			2	
H3335	018	0	1	04	01	H3335_018_0	5	2	Hearing Aid	10		18b;	2		2			2			2	
H3335	018	0	1	04	01	H3335_018_0	5	3	Ambulance	01	10a;		2		2			1	250.00	250.00	2	
H3335	018	0	1	04	01	H3335_018_0	5	4	$0 Copayment	10		14c;	1	150.00	2			2			2	
H3335	018	0	1	04	01	H3335_018_0	5	5	ESRD	01	12;		2		1	20	20	2			2	
H3335	018	0	1	04	01	H3335_018_0	5	6	Preventive Services	01	14a;		2		1	0	30	2			2	
H3335	018	0	1	04	01	H3335_018_0	5	7		10		18a;	2		2			1	75.00	75.00	2	
H3335	038	0	1	04	01	H3335_038_0	5	1	30% Coinsurance	11	5;6;7e;7h;8a1;8a2;8b1;8b2;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;	9d;14b;	2		1	30	30	2			2	
H3335	038	0	1	04	01	H3335_038_0	5	10	Hearing Aid	10		18b;	2		2			2			2	
H3335	038	0	1	04	01	H3335_038_0	5	11		10		18a;	2		2			1	75.00	75.00	2	
H3335	038	0	1	04	01	H3335_038_0	5	2	Vision	10		17b;	2		2			2			2	
H3335	038	0	1	04	01	H3335_038_0	5	3	Ambulance	01	10a;		2		2			1	240.00	240.00	2	
H3335	038	0	1	04	01	H3335_038_0	5	4	PT/OT/ST	01	7c;7i;		2		2			1	50.00	50.00	2	
H3335	038	0	1	04	01	H3335_038_0	5	5	Preventive Services	01	14a;		2		1	0	30	2			2	
H3335	038	0	1	04	01	H3335_038_0	5	6	Supplemental Education/Wellness Programs	10		14c;	1	150.00	2			2			2	
H3335	038	0	1	04	01	H3335_038_0	5	7	$25 Copayment	01	7a;7b;		2		2			1	25.00	25.00	2	
H3335	038	0	1	04	01	H3335_038_0	5	8	$60 Copayment - Specialist Services	11	3-1;3-2;3-3;7d;7f;7g;8b3;16b;17a;17b;18a;	17a;	2		2			1	60.00	60.00	2	
H3335	038	0	1	04	01	H3335_038_0	5	9	ESRD	01	12;		2		1	20	20	2			2	
H3335	041	0	1	04	01	H3335_041_0	4	1	30% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;	2		1	30	30	2			2	
H3335	041	0	1	04	01	H3335_041_0	4	2	Hearing Aids	10		18b;	2		2			2			2	
H3335	041	0	1	04	01	H3335_041_0	4	3	Ambulance	01	10a;		2		2			1	200.00	200.00	2	
H3335	041	0	1	04	01	H3335_041_0	4	4	$0 Copayment	10		14c;	1	150.00	2			2			2	
H3335	041	0	1	04	01	H3335_041_0	4	5	ESRD	01	12;		2		1	20	20	2			2	
H3335	041	0	1	04	01	H3335_041_0	4	6	Preventive Services	01	14a;		2		1	0	30	2			2	
H3335	041	0	1	04	01	H3335_041_0	4	7		10		18a;	2		2			1	75.00	75.00	2	
H3335	043	0	1	04	01	H3335_043_0	4	1	30% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;	2		1	30	30	2			2	
H3335	043	0	1	04	01	H3335_043_0	4	2	Hearing Aids	10		18b;	2		2			2			2	
H3335	043	0	1	04	01	H3335_043_0	4	3	Ambulance	01	10a;		2		2			1	200.00	200.00	2	
H3335	043	0	1	04	01	H3335_043_0	4	4	$0 Copayment	10		14c;	1	150.00	2			2			2	
H3335	043	0	1	04	01	H3335_043_0	4	5	ESRD	01	12;		2		1	20	20	2			2	
H3335	043	0	1	04	01	H3335_043_0	4	6	Preventive Services	01	14a;		2		1	0	30	2			2	
H3335	043	0	1	04	01	H3335_043_0	4	7		10		18a;	2		2			1	75.00	75.00	2	
H3335	044	0	1	04	01	H3335_044_0	4	1	30% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;	2		1	30	30	2			2	
H3335	044	0	1	04	01	H3335_044_0	4	2	Hearing Aids	10		18b;	2		2			2			2	
H3335	044	0	1	04	01	H3335_044_0	4	3	Ambulance	01	10a;		2		2			1	200.00	200.00	2	
H3335	044	0	1	04	01	H3335_044_0	4	4	$0 Copayment	10		14c;	1	150.00	2			2			2	
H3335	044	0	1	04	01	H3335_044_0	4	5	ESRD	01	12;		2		1	20	20	2			2	
H3335	044	0	1	04	01	H3335_044_0	4	6	Preventive Services	01	14a;		2		1	0	30	2			2	
H3335	044	0	1	04	01	H3335_044_0	4	7		10		18a;	2		2			1	75.00	75.00	2	
H3335	051	0	1	04	01	H3335_051_0	5	1	30% Coinsurance	11	5;6;7e;7h;8a1;8a2;8b1;8b2;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;	9d;14b;	2		1	30	30	2			2	
H3335	051	0	1	04	01	H3335_051_0	5	10	Hearing Aid	10		18b;	2		2			2			2	
H3335	051	0	1	04	01	H3335_051_0	5	11		10		18a;	2		2			1	75.00	75.00	2	
H3335	051	0	1	04	01	H3335_051_0	5	2	Vision	10		17b;	2		2			2			2	
H3335	051	0	1	04	01	H3335_051_0	5	3	Ambulance	01	10a;		2		2			1	240.00	240.00	2	
H3335	051	0	1	04	01	H3335_051_0	5	4	PT/OT/ST	01	7c;7i;		2		2			1	50.00	50.00	2	
H3335	051	0	1	04	01	H3335_051_0	5	5	Preventive Services	01	14a;		2		1	0	30	2			2	
H3335	051	0	1	04	01	H3335_051_0	5	6	Supplemental Education/Wellness Programs	10		14c;	1	150.00	2			2			2	
H3335	051	0	1	04	01	H3335_051_0	5	7	$25 Copayment	01	7a;7b;		2		2			1	25.00	25.00	2	
H3335	051	0	1	04	01	H3335_051_0	5	8	$60 Copayment - Specialist Services	11	3-1;3-2;3-3;7d;7f;7g;8b3;16b;17a;17b;18a;	17a;	2		2			1	60.00	60.00	2	
H3335	051	0	1	04	01	H3335_051_0	5	9	ESRD	01	12;		2		1	20	20	2			2	
H3335	053	0	1	04	01	H3335_053_0	5	1	30% Coinsurance	11	5;6;7e;7h;8a1;8a2;8b1;8b2;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;	9d;14b;	2		1	30	30	2			2	
H3335	053	0	1	04	01	H3335_053_0	5	10	Hearing Aid	10		18b;	2		2			2			2	
H3335	053	0	1	04	01	H3335_053_0	5	11		10		18a;	2		2			1	75.00	75.00	2	
H3335	053	0	1	04	01	H3335_053_0	5	2	Eyewear Allowance	10		17b;	2		2			2			2	
H3335	053	0	1	04	01	H3335_053_0	5	3	Ambulance	01	10a;		2		2			1	250.00	250.00	2	
H3335	053	0	1	04	01	H3335_053_0	5	4	PT/OT/ST	01	7c;7i;		2		2			1	50.00	50.00	2	
H3335	053	0	1	04	01	H3335_053_0	5	5	Preventive Services	01	14a;		2		1	0	30	2			2	
H3335	053	0	1	04	01	H3335_053_0	5	6	Supplemental Education/Wellness Programs	10		14c;	1	150.00	2			2			2	
H3335	053	0	1	04	01	H3335_053_0	5	7	$25 Copayment	01	7a;7b;		2		2			1	25.00	25.00	2	
H3335	053	0	1	04	01	H3335_053_0	5	8	$60 Copayment - Specialist Services	11	3-1;3-2;3-3;7d;7f;7g;8b3;16b;17a;17b;18a;	17a;	2		2			1	60.00	60.00	2	
H3335	053	0	1	04	01	H3335_053_0	5	9	ESRD	01	12;		2		1	20	20	2			2	
H3335	054	0	1	04	01	H3335_054_0	5	1	30% Coinsurance	11	5;6;7e;7h;8a1;8a2;8b1;8b2;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;	9d;14b;	2		1	30	30	2			2	
H3335	054	0	1	04	01	H3335_054_0	5	10	Hearing Aid	10		18b;	2		2			2			2	
H3335	054	0	1	04	01	H3335_054_0	5	11		10		18a;	2		2			1	75.00	75.00	2	
H3335	054	0	1	04	01	H3335_054_0	5	2	Eyewear Allowance	10		17b;	2		2			2			2	
H3335	054	0	1	04	01	H3335_054_0	5	3	Ambulance	01	10a;		2		2			1	250.00	250.00	2	
H3335	054	0	1	04	01	H3335_054_0	5	4	PT/OT/ST	01	7c;7i;		2		2			1	50.00	50.00	2	
H3335	054	0	1	04	01	H3335_054_0	5	5	Preventive Services	01	14a;		2		1	0	30	2			2	
H3335	054	0	1	04	01	H3335_054_0	5	6	Supplemental Education/Wellness Programs	10		14c;	1	150.00	2			2			2	
H3335	054	0	1	04	01	H3335_054_0	5	7	$25 Copayment	01	7a;7b;		2		2			1	25.00	25.00	2	
H3335	054	0	1	04	01	H3335_054_0	5	8	$60 Copayment - Specialist Services	11	3-1;3-2;3-3;7d;7f;7g;8b3;16b;17a;17b;18a;	17a;	2		2			1	60.00	60.00	2	
H3335	054	0	1	04	01	H3335_054_0	5	9	ESRD	01	12;		2		1	20	20	2			2	
H3335	801	0	1	04	01	H3335_801_0	1	1		01	6;14a;		2		1	0	0	2			2	
H3335	801	0	1	04	01	H3335_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3335	811	0	1	04	01	H3335_811_0	1	1		01	6;14a;		2		1	0	0	2			2	
H3335	811	0	1	04	01	H3335_811_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3335	813	0	1	04	01	H3335_813_0	1	1	20% Coinsurance	01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3335	813	0	1	04	01	H3335_813_0	1	2	$0 Copayment	01	6;14e;		2		2			1	0.00	0.00	2	
H3335	819	0	1	04	01	H3335_819_0	1	1		01	6;14a;		2		1	0	0	2			2	
H3335	819	0	1	04	01	H3335_819_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3335	820	0	1	04	01	H3335_820_0	1	1		01	6;14a;		2		1	0	0	2			2	
H3335	820	0	1	04	01	H3335_820_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3335	822	0	1	04	01	H3335_822_0	1	1		01	6;14a;		2		1	0	0	2			2	
H3335	822	0	1	04	01	H3335_822_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3342	019	0	1	04	01	H3342_019_0	5	1	$0 Copay	11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H3342	019	0	1	04	01	H3342_019_0	5	2	$50 Copay	01	7a;7g;		2		2			1	50.00	50.00	2	
H3342	019	0	1	04	01	H3342_019_0	5	3	$75 Copay	01	7b;7c;7d;7e;7f;7h;7i;		2		2			1	75.00	75.00	2	
H3342	019	0	1	04	01	H3342_019_0	5	4	40% Coinsurance	11	3-1;3-2;3-3;5;6;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;	14b;	2		1	40	40	2			2	
H3342	019	0	1	04	01	H3342_019_0	5	5	Ambulance	01	10a;		2		1	20	20	1	295.00	295.00	2	
H3342	019	0	1	04	01	H3342_019_0	5	6	20% Coinsurance	11	12;16b;	16a;	2		1	20	20	2			2	
H3342	019	0	1	04	01	H3342_019_0	5	7	Eligible Supplemental Benefits	10		14c;	1	95.00	2			1	0.00	0.00	2	
H3342	808	0	1	04	01	H3342_808_0	1	1		01	6;14a;		2		1	0	0	2			2	
H3342	808	0	1	04	01	H3342_808_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3342	809	0	1	04	01	H3342_809_0	1	1		01	6;14a;		2		1	0	0	2			2	
H3342	809	0	1	04	01	H3342_809_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3342	810	0	1	04	01	H3342_810_0	2	1		01	6;14a;		2		1	0	0	2			2	
H3342	810	0	1	04	01	H3342_810_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3344	005	0	1	04	01	H3344_005_0	9	1	$0	01	17b;		2		2			2			2	
H3344	005	0	1	04	01	H3344_005_0	9	10	Non-medicare covered eyewear	10		17b;	1	200.00	2			2			2	
H3344	005	0	1	04	01	H3344_005_0	9	11	45% OON	01	9c;		2		1	45	45	2			2	
H3344	005	0	1	04	01	H3344_005_0	9	12	Routine Vision Exam	10		17a;	2		2			1	65.00	65.00	2	
H3344	005	0	1	04	01	H3344_005_0	9	2	40% coinsurance	11	3-1;3-2;3-3;6;7b;7c;7e;7h;7i;8a1;8a2;8b1;8b3;9a;9b;9d;11c;14a;14d;14e;15;18a;	9d;14b;14c;15;18a;	2		1	40	40	2			2	
H3344	005	0	1	04	01	H3344_005_0	9	3	$250	01	10a;		2		2			1	250.00	250.00	2	
H3344	005	0	1	04	01	H3344_005_0	9	4	50 non prev dental	10		16a;	2		1	50	50	1	20.00	20.00	2	
H3344	005	0	1	04	01	H3344_005_0	9	5	$75 copayment	01	7d;7f;7g;16b;17a;		2		2			1	75.00	75.00	2	
H3344	005	0	1	04	01	H3344_005_0	9	6	50% coinsurance	01	5;8b2;11a;11b;		2		1	50	50	2			2	
H3344	005	0	1	04	01	H3344_005_0	9	7	20%	01	12;		2		1	20	20	2			2	
H3344	005	0	1	04	01	H3344_005_0	9	8	Hearing Aids TruHearing National Network	10		18b;	2		2			1	599.00	899.00	2	
H3344	005	0	1	04	01	H3344_005_0	9	9	$25	01	7a;		2		2			1	25.00	25.00	2	
H3344	801	0	1	04	01	H3344_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
H3344	801	0	1	04	01	H3344_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3344	804	0	1	04	01	H3344_804_0	2	1		01	6;14a;		2		1	0	0	2			2	
H3344	804	0	1	04	01	H3344_804_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3404	003	1	1	04	01	H3404_003_1	7	1	$250	01	10a;		2		2			1	250.00	250.00	2	
H3404	003	1	1	04	01	H3404_003_1	7	2	$0	11	14a;14d;14e;	14b;	2		2			1	0.00	0.00	2	
H3404	003	1	1	04	01	H3404_003_1	7	3	40%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;15;16b;17a;17b;18a;	9d;17a;	2		1	40	40	2			2	
H3404	003	2	1	04	01	H3404_003_2	8	1	$250	01	10a;		2		2			1	250.00	250.00	2	
H3404	003	2	1	04	01	H3404_003_2	8	2	$0	11	14a;14d;14e;	14b;	2		2			1	0.00	0.00	2	
H3404	003	2	1	04	01	H3404_003_2	8	3	40%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;15;16b;17a;17b;18a;	9d;17a;	2		1	40	40	2			2	
H3404	801	0	1	04	01	H3404_801_0	5	1		01	6;14a;		2		1	0	0	2			2	
H3404	801	0	1	04	01	H3404_801_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3404	803	0	1	04	01	H3404_803_0	5	1		01	6;14a;		2		1	0	0	2			2	
H3404	803	0	1	04	01	H3404_803_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3404	809	0	1	04	01	H3404_809_0	4	1		01	6;14a;		2		1	0	0	2			2	
H3404	809	0	1	04	01	H3404_809_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3416	001	4	1	04	01	H3416_001_4	7	1	Benefits with OON Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	40	40	2			2	
H3416	001	4	1	04	01	H3416_001_4	7	2	Ambulance Services OON	01	10a;		2		2			1	215.00	215.00	2	
H3416	001	4	1	04	01	H3416_001_4	7	3	Dialysis Services OON	01	12;		2		1	20	20	2			2	
H3416	001	4	1	04	01	H3416_001_4	7	4	US Emergency Travel Logistics	10		13d;	2		1	40	40	2			2	
H3416	001	4	1	04	01	H3416_001_4	7	5	OON Preventive Dental	10		16a;	2		2			2			2	
H3416	001	4	1	04	01	H3416_001_4	7	6	Benefits with OON Coinsurance Range	10		14c;	2		1	40	50	2			2	
H3416	001	5	1	04	01	H3416_001_5	7	1	Benefits with OON Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	40	40	2			2	
H3416	001	5	1	04	01	H3416_001_5	7	2	Ambulance Services OON	01	10a;		2		2			1	215.00	215.00	2	
H3416	001	5	1	04	01	H3416_001_5	7	3	Dialysis Services OON	01	12;		2		1	20	20	2			2	
H3416	001	5	1	04	01	H3416_001_5	7	4	US emergency travel logistics	10		13d;	2		1	40	40	2			2	
H3416	001	5	1	04	01	H3416_001_5	7	5	OON Preventive Dental	10		16a;	2		2			2			2	
H3416	001	5	1	04	01	H3416_001_5	7	6	Benefits with OON Coinsurance Range	10		14c;	2		1	40	50	2			2	
H3416	002	2	1	04	01	H3416_002_2	7	1	Benefits with OON Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	30	30	2			2	
H3416	002	2	1	04	01	H3416_002_2	7	2	Ambulance Services OON	01	10a;		2		2			1	215.00	215.00	2	
H3416	002	2	1	04	01	H3416_002_2	7	3	Dialysis Services OON	01	12;		2		2			2			2	
H3416	002	2	1	04	01	H3416_002_2	7	4	US emergency travel logistics	10		13d;	2		1	30	30	2			2	
H3416	002	2	1	04	01	H3416_002_2	7	5	OON Preventive Dental	10		16a;	2		2			2			2	
H3416	002	2	1	04	01	H3416_002_2	7	6	Benefits with OON Coinsurance Range	10		14c;	2		1	30	50	2			2	
H3416	002	3	1	04	01	H3416_002_3	7	1	Benefits with OON Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	30	30	2			2	
H3416	002	3	1	04	01	H3416_002_3	7	2	Ambulance Services OON	01	10a;		2		2			1	215.00	215.00	2	
H3416	002	3	1	04	01	H3416_002_3	7	3	Dialysis Services OON	01	12;		2		2			2			2	
H3416	002	3	1	04	01	H3416_002_3	7	4	US emergency travel logistics	10		13d;	2		1	30	30	2			2	
H3416	002	3	1	04	01	H3416_002_3	7	5	OON Preventive Dental	10		16a;	2		2			2			2	
H3416	002	3	1	04	01	H3416_002_3	7	6	Benefits with OON Coinsurance Range	10		14c;	2		1	30	50	2			2	
H3416	801	0	1	04	01	H3416_801_0	3	1	OON Benefits	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;		2		1	50	50	2			2	
H3416	803	0	1	04	01	H3416_803_0	2	1	OON Benefits	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;		2		1	50	50	2			2	
H3533	001	0	1	01	01	H3533_001_0	4	1														
H3533	002	0	1	01	01	H3533_002_0	4	1														
H3533	004	0	1	01	01	H3533_004_0	4	1														
H3533	006	0	1	01	01	H3533_006_0	5	1														
H3533	010	0	1	01	01	H3533_010_0	5	1														
H3533	013	0	1	01	01	H3533_013_0	4	1														
H3533	020	0	1	01	01	H3533_020_0	4	1														
H3533	021	0	1	01	01	H3533_021_0	5	1														
H3533	023	0	1	01	01	H3533_023_0	4	1														
H3533	027	0	1	01	01	H3533_027_0	5	1														
H3813	001	0	1	04	01	H3813_001_0	6	1	$0 Copayment	11	6;8a1;8a2;9d;14a;14d;14e;17a;17b;	14c;	2		2			2			2	
H3813	001	0	1	04	01	H3813_001_0	6	2	$35 Copayment	11	3-1;3-2;3-3;5;7c;7d;7f;7i;16b;	17a;	2		2			1	35.00	35.00	2	
H3813	001	0	1	04	01	H3813_001_0	6	3	20% Coinsurance	01	8b1;8b2;8b3;11a;11b;12;15;		2		1	20	20	2			2	
H3813	001	0	1	04	01	H3813_001_0	6	4	$20-$35 copay	01	7g;		2		2			1	20.00	35.00	2	
H3813	001	0	1	04	01	H3813_001_0	6	5	$20 Copayment	01	7a;7b;7e;7h;9c;		2		2			1	20.00	20.00	2	
H3813	001	0	1	04	01	H3813_001_0	6	6	$100 Copayment	01	10a;		2		2			1	100.00	100.00	2	
H3813	001	0	1	04	01	H3813_001_0	6	7	$300 Copayment	01	9a;9b;		2		2			1	300.00	300.00	2	
H3813	001	0	1	04	01	H3813_001_0	6	8	$0 or 20%	01	11c;		2		1	0	20	2			2	
H3813	001	0	1	04	01	H3813_001_0	6	9	$25 Copayment	01	18a;		2		2			1	25.00	25.00	2	
H3813	006	0	1	04	01	H3813_006_0	9	1	$0 copayment	11	8a1;8a2;9d;14a;14d;14e;17a;17b;	14c;	2		2			2			2	
H3813	006	0	1	04	01	H3813_006_0	9	2	20% coinsurance	01	12;		2		1	20	20	2			2	
H3813	006	0	1	04	01	H3813_006_0	9	3	$40 copayment	01	7a;7b;7e;7h;9c;		2		2			1	40.00	40.00	2	
H3813	006	0	1	04	01	H3813_006_0	9	4	$50 copayment	01	3-1;3-2;3-3;5;7c;7d;7f;7i;16b;18a;		2		2			1	50.00	50.00	2	
H3813	006	0	1	04	01	H3813_006_0	9	5	$35 - $50 copayment	01	7g;		2		2			1	35.00	50.00	2	
H3813	006	0	1	04	01	H3813_006_0	9	6	$35 copayment	10		17a;	2		2			1	35.00	35.00	2	
H3813	006	0	1	04	01	H3813_006_0	9	7	30% coinsurance	01	6;8b1;8b2;8b3;9a;9b;11a;11b;15;		2		1	30	30	2			2	
H3813	006	0	1	04	01	H3813_006_0	9	8	$250 copayment	01	10a;		2		2			1	250.00	250.00	2	
H3813	006	0	1	04	01	H3813_006_0	9	9	$0 or 30% coinsurance	01	11c;		2		1	0	30	2			2	
H3813	802	0	1	04	01	H3813_802_0	4	1	$0 copay	11	6;9d;14a;14d;14e;17a;17b;	14c;17b;	2		2			2			2	
H3813	802	0	1	04	01	H3813_802_0	4	10	$25 copay	01	7a;		2		2			1	25.00	25.00	2	
H3813	802	0	1	04	01	H3813_802_0	4	2	10% - 30% coinsurance	01	11c;		2		1	10	30	2			2	
H3813	802	0	1	04	01	H3813_802_0	4	3	$20 - $30 copayment	01	7g;		2		2			1	20.00	30.00	2	
H3813	802	0	1	04	01	H3813_802_0	4	4	$20 copay	10		17a;	2		2			1	20.00	20.00	2	
H3813	802	0	1	04	01	H3813_802_0	4	5	10% coinsurance	01	12;		2		1	10	10	2			2	
H3813	802	0	1	04	01	H3813_802_0	4	6	$50 copay	01	10a;		2		2			1	50.00	50.00	2	
H3813	802	0	1	04	01	H3813_802_0	4	7	$30 copay	01	3-1;3-2;3-3;5;7b;7c;7d;7e;7f;7h;7i;9c;16b;18a;		2		2			1	30.00	30.00	2	
H3813	802	0	1	04	01	H3813_802_0	4	8	20% coinsurance	01	8a1;8a2;8b1;8b2;8b3;9a;9b;15;		2		1	20	20	2			2	
H3813	802	0	1	04	01	H3813_802_0	4	9	30% coinsurance	01	11a;11b;		2		1	30	30	2			2	
H3817	007	1	1	04	01	H3817_007_1	8	1	Routine Eye Exam and Eyewear	10		17a;17b;	2		2			1	0.00	0.00	2	
H3817	007	1	1	04	01	H3817_007_1	8	2	Eligible Supplemental Benefits	10		14c;	2		2			1	0.00	0.00	2	
H3817	007	1	1	04	01	H3817_007_1	8	3	Ambulance Services	01	10a;		2		2			1	275.00	275.00	2	
H3817	007	1	1	04	01	H3817_007_1	8	4	All Other OON 50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;16a;	2		1	50	50	2			2	
H3817	007	2	1	04	01	H3817_007_2	8	1	Routine Eye Exam and Eyewear	10		17a;17b;	2		2			1	0.00	0.00	2	
H3817	007	2	1	04	01	H3817_007_2	8	2	Eligible Supplemental Benefits	10		14c;	2		2			1	0.00	0.00	2	
H3817	007	2	1	04	01	H3817_007_2	8	3	Ambulance Services	01	10a;		2		2			1	275.00	275.00	2	
H3817	007	2	1	04	01	H3817_007_2	8	4	All Other OON 50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;16a;	2		1	50	50	2			2	
H3817	008	1	1	04	01	H3817_008_1	9	1	Routine Eye Exam and Eyewear	10		17a;17b;	2		2			1	0.00	0.00	2	
H3817	008	1	1	04	01	H3817_008_1	9	2	Eligible Supplemental Benefits	10		14c;	2		2			1	0.00	0.00	2	
H3817	008	1	1	04	01	H3817_008_1	9	3	Ambulance Services	01	10a;		2		2			1	275.00	275.00	2	
H3817	008	1	1	04	01	H3817_008_1	9	4	All Other OON 50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;16a;	2		1	50	50	2			2	
H3817	008	2	1	04	01	H3817_008_2	9	1	Routine Eye Exam and Eyewear	10		17a;17b;	2		2			1	0.00	0.00	2	
H3817	008	2	1	04	01	H3817_008_2	9	2	Eligible Supplemental Benefits	10		14c;	2		2			1	0.00	0.00	2	
H3817	008	2	1	04	01	H3817_008_2	9	3	Ambulance Services	01	10a;		2		2			1	275.00	275.00	2	
H3817	008	2	1	04	01	H3817_008_2	9	4	All Other OON 50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;16a;	2		1	50	50	2			2	
H3817	009	1	1	04	01	H3817_009_1	8	1	Routine Eye Exam and Eyewear	10		17a;17b;	2		2			1	0.00	0.00	2	
H3817	009	1	1	04	01	H3817_009_1	8	2	Eligible Supplemental Benefits	10		14c;	2		2			1	0.00	0.00	2	
H3817	009	1	1	04	01	H3817_009_1	8	3	Ambulance Services	01	10a;		2		2			1	250.00	250.00	2	
H3817	009	1	1	04	01	H3817_009_1	8	4	All Other OON 50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;16a;16b;	2		1	50	50	2			2	
H3817	009	1	1	04	01	H3817_009_1	8	5	Hearing Exams	10		18a;	2		2			1	150.00	150.00	2	
H3817	009	1	1	04	01	H3817_009_1	8	6	Hearing Aids	10		18b;	2		2			1	599.00	899.00	2	
H3817	009	2	1	04	01	H3817_009_2	8	1	Routine Eye Exam and Eyewear	10		17a;17b;	2		2			1	0.00	0.00	2	
H3817	009	2	1	04	01	H3817_009_2	8	2	Eligible Supplemental Benefits	10		14c;	2		2			1	0.00	0.00	2	
H3817	009	2	1	04	01	H3817_009_2	8	3	Ambulance Services	01	10a;		2		2			1	250.00	250.00	2	
H3817	009	2	1	04	01	H3817_009_2	8	4	All Other OON 50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;16a;16b;	2		1	50	50	2			2	
H3817	009	2	1	04	01	H3817_009_2	8	5	Hearing Exams	10		18a;	2		2			1	150.00	150.00	2	
H3817	009	2	1	04	01	H3817_009_2	8	6	Hearing Aids	10		18b;	2		2			1	599.00	899.00	2	
H3817	801	0	1	04	01	H3817_801_0	3	1		01	6;14a;		2		1	0	0	2			2	
H3817	801	0	1	04	01	H3817_801_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3817	802	0	1	04	01	H3817_802_0	3	1		01	6;14a;		2		1	0	0	2			2	
H3817	802	0	1	04	01	H3817_802_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3832	007	0	1	04	01	H3832_007_0	11	1	Group 1 - 30%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;15;16b;17a;18a;	17a;	2		1	30	30	2			2	
H3832	007	0	1	04	01	H3832_007_0	11	2	Group 2 - $0	11	9d;14a;14d;14e;17b;	9d;17b;	2		2			1	0.00	0.00	2	
H3832	007	0	1	04	01	H3832_007_0	11	3	Group 3 - $250	01	10a;		2		2			1	250.00	250.00	2	
H3832	007	0	1	04	01	H3832_007_0	11	4	Group 4 - 20%	01	12;		2		1	20	20	2			2	
H3832	007	0	1	04	01	H3832_007_0	11	5	Group 5 - $0-$15	10		14c;	2		2			1	0.00	15.00	2	
H3832	008	0	1	04	01	H3832_008_0	9	1	Group 1 - 30%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;15;16b;17a;18a;	17a;	2		1	30	30	2			2	
H3832	008	0	1	04	01	H3832_008_0	9	2	Group 2 - $0	11	9d;14a;14d;14e;17b;	9d;17b;	2		2			1	0.00	0.00	2	
H3832	008	0	1	04	01	H3832_008_0	9	3	Group 3 - $225	01	10a;		2		2			1	225.00	225.00	2	
H3832	008	0	1	04	01	H3832_008_0	9	4	Group 4 - 20%	01	12;		2		1	20	20	2			2	
H3832	008	0	1	04	01	H3832_008_0	9	5	Group #5 - $0-15	10		14c;	2		2			1	0.00	15.00	2	
H3832	009	0	1	04	01	H3832_009_0	7	1	Group 1 - 30%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;15;16b;17a;18a;	17a;	2		1	30	30	2			2	
H3832	009	0	1	04	01	H3832_009_0	7	2	Group 2 - $0	11	9d;14a;14d;14e;17b;	9d;17b;	2		2			1	0.00	0.00	2	
H3832	009	0	1	04	01	H3832_009_0	7	3	Group 3 - $250	01	10a;		2		2			1	250.00	250.00	2	
H3832	009	0	1	04	01	H3832_009_0	7	4	Group 4 - 20%	01	12;		2		1	20	20	2			2	
H3832	009	0	1	04	01	H3832_009_0	7	5	Group #5 - $0 to $15 copayment	10		14c;	2		2			1	0.00	15.00	2	
H3832	010	0	1	04	01	H3832_010_0	6	1	Group 1 - 30%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;15;16b;17a;18a;	17a;	2		1	30	30	2			2	
H3832	010	0	1	04	01	H3832_010_0	6	2	Group 2 - $0	11	9d;14a;14d;14e;17b;	9d;17b;	2		2			1	0.00	0.00	2	
H3832	010	0	1	04	01	H3832_010_0	6	3	Group 3 - $225	01	10a;		2		2			1	225.00	225.00	2	
H3832	010	0	1	04	01	H3832_010_0	6	4	Group 4- 20%	01	12;		2		1	20	20	2			2	
H3832	010	0	1	04	01	H3832_010_0	6	5	Group #5- $0-$15 copayment	10		14c;	2		2			1	0.00	15.00	2	
H3832	011	0	1	04	01	H3832_011_0	8	1	Group 1 - $0	11	14a;	14c;	2		2			1	0.00	0.00	2	
H3832	011	0	1	04	01	H3832_011_0	8	2	Group 2: 30%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;14d;14e;15;16b;17a;17b;18a;	9d;	2		1	30	30	2			2	
H3832	011	0	1	04	01	H3832_011_0	8	3	Group 3 - 50%	10		16a;16b;	2		1	50	50	2			2	
H3832	011	0	1	04	01	H3832_011_0	8	4	Group 4 - 20%	01	12;		2		1	20	20	2			2	
H3832	801	0	1	04	01	H3832_801_0	1	1		01	6;14a;		2		1	0	0	2			2	
H3832	801	0	1	04	01	H3832_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3832	802	0	1	04	01	H3832_802_0	1	1		01	6;14a;		2		1	0	0	2			2	
H3832	802	0	1	04	01	H3832_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3832	805	0	1	04	01	H3832_805_0	1	1		01	6;14a;		2		1	0	0	2			2	
H3832	805	0	1	04	01	H3832_805_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3832	807	0	1	04	01	H3832_807_0	1	1		01	6;14a;		2		1	0	0	2			2	
H3832	807	0	1	04	01	H3832_807_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3890	001	0	1	04	01	H3890_001_0	5	1	OON - 50% Coinsurance	11	7b;7e;7h;8a1;8a2;8b1;8b2;9a;9b;9c;11a;11b;12;14a;14d;14e;16b;17a;17b;18a;	14b;16a;17a;18a;	2		1	50	50	2			2	
H3890	001	0	1	04	01	H3890_001_0	5	2	OON - 30% Coinsurance	01	5;6;7a;7d;7g;8b3;		2		1	30	30	2			2	
H3890	001	0	1	04	01	H3890_001_0	5	3	Ambulance Services	01	10a;		2		2			1	300.00	300.00	2	
H3890	001	0	1	04	01	H3890_001_0	5	4	Nurseline + Blood Services	11	9d;	9d;14c;	2		2			2			2	
H3890	001	0	1	04	01	H3890_001_0	5	5	OON - 40% Coinsurace	11	3-1;3-2;3-3;7c;7f;7i;11c;15;	7f;	2		1	40	40	2			2	
H3890	001	0	1	04	01	H3890_001_0	5	6	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H3890	002	0	1	04	01	H3890_002_0	5	1	OON - 20% Coinsurance	01	5;8b3;		2		1	20	20	2			2	
H3890	002	0	1	04	01	H3890_002_0	5	2	OON - 30% Coinsurance	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7f;7g;7i;11c;15;	7b;7f;	2		1	30	30	2			2	
H3890	002	0	1	04	01	H3890_002_0	5	3	Ambulance Services	01	10a;		2		2			1	300.00	300.00	2	
H3890	002	0	1	04	01	H3890_002_0	5	4	Acupuncture	10		13a;	1	200.00	2			2			2	
H3890	002	0	1	04	01	H3890_002_0	5	5	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H3890	002	0	1	04	01	H3890_002_0	5	6	Fitness and Nurseline	10		14c;	2		2			2			2	
H3890	002	0	1	04	01	H3890_002_0	5	7	45% Coinsurance	11	7e;7h;8a1;8a2;8b1;8b2;9a;9b;9c;11a;11b;12;14a;14d;14e;16b;17a;17b;18a;	14b;16a;18a;	2		1	45	45	2			2	
H3890	002	0	1	04	01	H3890_002_0	5	8	Blood Services	11	9d;	9d;	2		2			2			2	
H3890	002	0	1	04	01	H3890_002_0	5	9	Vision	10		17a;17b;	2		1	45	45	2			2	
H3890	801	0	1	04	01	H3890_801_0	3	1		01	6;14a;		2		1	0	0	2			2	
H3890	801	0	1	04	01	H3890_801_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3890	802	0	1	04	01	H3890_802_0	3	1		01	6;14a;		2		1	0	0	2			2	
H3890	802	0	1	04	01	H3890_802_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3890	803	0	1	04	01	H3890_803_0	3	1		01	6;14a;		2		1	0	0	2			2	
H3890	803	0	1	04	01	H3890_803_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3909	001	0	1	04	01	H3909_001_0	4	1	30% OON	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	7b;7f;9d;14b;18a;	2		1	30	30	2			2	
H3909	001	0	1	04	01	H3909_001_0	4	2	OON Hearing Aid	10		18b;	2		2			1	699.00	999.00	2	
H3909	001	0	1	04	01	H3909_001_0	4	3	OON Ambulance	01	10a;		2		2			1	175.00	175.00	2	
H3909	001	0	1	04	01	H3909_001_0	4	4	OON Supplemental Benefits	10		14c;	2		2			2			2	
H3909	001	0	1	04	01	H3909_001_0	4	5	OON Dialysis	01	12;		2		1	20	20	2			2	
H3909	007	0	1	04	01	H3909_007_0	2	1	30% OON	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	7b;7f;9d;14b;18a;	2		1	30	30	2			2	
H3909	007	0	1	04	01	H3909_007_0	2	2	OON Hearing Aid	10		18b;	2		2			1	699.00	999.00	2	
H3909	007	0	1	04	01	H3909_007_0	2	3	OON Ambulance	01	10a;		2		2			1	175.00	175.00	2	
H3909	007	0	1	04	01	H3909_007_0	2	4	OON Supplemental Benefits	10		14c;	2		2			2			2	
H3909	007	0	1	04	01	H3909_007_0	2	5	OON Dialysis	01	12;		2		1	20	20	2			2	
H3909	009	0	1	04	01	H3909_009_0	3	1	30% OON	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	7b;7f;9d;14b;18a;	2		1	30	30	2			2	
H3909	009	0	1	04	01	H3909_009_0	3	2	OON Hearing Aid	10		18b;	2		2			1	699.00	999.00	2	
H3909	009	0	1	04	01	H3909_009_0	3	3	OON Ambulance	01	10a;		2		2			1	175.00	175.00	2	
H3909	009	0	1	04	01	H3909_009_0	3	4	OON Supplemental Benefits	10		14c;	2		2			2			2	
H3909	009	0	1	04	01	H3909_009_0	3	5	OON Dialysis	01	12;		2		1	20	20	2			2	
H3909	801	0	1	04	01	H3909_801_0	1	1		01	6;14a;		2		1	0	0	2			2	
H3909	801	0	1	04	01	H3909_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3909	802	0	1	04	01	H3909_802_0	1	1		01	6;14a;		2		1	0	0	2			2	
H3909	802	0	1	04	01	H3909_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3916	001	0	1	04	01	H3916_001_0	10	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;16b;18a;	7b;7f;9d;18a;	2		1	30	30	2			2	
H3916	001	0	1	04	01	H3916_001_0	10	10	Routine Eye Exams	10		17a;	2		2			1	50.00	50.00	2	
H3916	001	0	1	04	01	H3916_001_0	10	11	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H3916	001	0	1	04	01	H3916_001_0	10	2	Preventive Services and Routine Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2			2	
H3916	001	0	1	04	01	H3916_001_0	10	3	Ambulance	01	10a;		2		1	30	30	1	125.00	125.00	2	
H3916	001	0	1	04	01	H3916_001_0	10	4	Transportation and Preventive Dental	10		10b;16a;	2		1	50	50	2			2	
H3916	001	0	1	04	01	H3916_001_0	10	5	Fitness Benefit	10		14c;	2		1	50	50	2			1	500.00
H3916	001	0	1	04	01	H3916_001_0	10	6	Primary Care Physician	01	7a;		2		2			1	10.00	10.00	2	
H3916	001	0	1	04	01	H3916_001_0	10	7	Specialist  and Non-routine Eye Exam	01	7d;17a;		2		2			1	35.00	35.00	2	
H3916	001	0	1	04	01	H3916_001_0	10	8	End Stage Renal Disease	01	12;		2		1	20	30	2			2	
H3916	001	0	1	04	01	H3916_001_0	10	9	Part B Drugs	01	15;		2		1	30	30	2			2	
H3916	002	0	1	04	01	H3916_002_0	11	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;16b;18a;	7b;7f;9d;18a;	2		1	30	30	2			2	
H3916	002	0	1	04	01	H3916_002_0	11	10	Routine Eye Exams	10		17a;	2		2			1	50.00	50.00	2	
H3916	002	0	1	04	01	H3916_002_0	11	11	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H3916	002	0	1	04	01	H3916_002_0	11	2	Preventive Services and Routine Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2			2	
H3916	002	0	1	04	01	H3916_002_0	11	3	Ambulance	01	10a;		2		1	30	30	1	125.00	125.00	2	
H3916	002	0	1	04	01	H3916_002_0	11	4	Transportation and Preventive Dental	10		10b;16a;	2		1	50	50	2			2	
H3916	002	0	1	04	01	H3916_002_0	11	5	Fitness Benefit	10		14c;	2		1	50	50	2			1	500.00
H3916	002	0	1	04	01	H3916_002_0	11	6	Primary Care Physician	01	7a;		2		2			1	10.00	10.00	2	
H3916	002	0	1	04	01	H3916_002_0	11	7	Specialist  and Non-routine Eye Exam	01	7d;17a;		2		2			1	35.00	35.00	2	
H3916	002	0	1	04	01	H3916_002_0	11	8	End Stage Renal Disease	01	12;		2		1	20	30	2			2	
H3916	002	0	1	04	01	H3916_002_0	11	9	Part B Drugs	01	15;		2		1	30	30	2			2	
H3916	005	0	1	04	01	H3916_005_0	10	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;16b;18a;	7b;7f;9d;18a;	2		1	30	30	2			2	
H3916	005	0	1	04	01	H3916_005_0	10	10	Routine Eye Exams	10		17a;	2		2			1	50.00	50.00	2	
H3916	005	0	1	04	01	H3916_005_0	10	11	Hearing Aids	10		18b;	2		2			1	499.00	799.00	2	
H3916	005	0	1	04	01	H3916_005_0	10	2	Preventive Services and Routine Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2			2	
H3916	005	0	1	04	01	H3916_005_0	10	3	Ambulance	01	10a;		2		1	30	30	1	150.00	150.00	2	
H3916	005	0	1	04	01	H3916_005_0	10	4	Transportation and Preventive Dental	10		10b;16a;	2		1	50	50	2			2	
H3916	005	0	1	04	01	H3916_005_0	10	5	Fitness Benefit	10		14c;	2		1	50	50	2			1	500.00
H3916	005	0	1	04	01	H3916_005_0	10	6	Primary Care Physician	01	7a;		2		2			1	30.00	30.00	2	
H3916	005	0	1	04	01	H3916_005_0	10	7	Specialist and Non-routine Eye Exam	01	7d;17a;		2		2			1	40.00	40.00	2	
H3916	005	0	1	04	01	H3916_005_0	10	8	End Stage Renal Disease	01	12;		2		1	20	30	2			2	
H3916	005	0	1	04	01	H3916_005_0	10	9	Medicare Part B Rx Drugs	01	15;		2		1	30	30	2			2	
H3916	012	0	1	04	01	H3916_012_0	9	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;16b;18a;	7b;7f;9d;18a;	2		1	30	30	2			2	
H3916	012	0	1	04	01	H3916_012_0	9	10	Routine Eye Exams	10		17a;	2		2			1	50.00	50.00	2	
H3916	012	0	1	04	01	H3916_012_0	9	11	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H3916	012	0	1	04	01	H3916_012_0	9	2	Preventive Services and Routine Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2			2	
H3916	012	0	1	04	01	H3916_012_0	9	3	Ambulance	01	10a;		2		1	30	30	1	125.00	125.00	2	
H3916	012	0	1	04	01	H3916_012_0	9	4	Transportation and Preventive Dental	10		10b;16a;	2		1	50	50	2			2	
H3916	012	0	1	04	01	H3916_012_0	9	5	Fitness Benefit	10		14c;	2		1	50	50	2			1	500.00
H3916	012	0	1	04	01	H3916_012_0	9	6	Primary Care Physician	01	7a;		2		2			1	30.00	30.00	2	
H3916	012	0	1	04	01	H3916_012_0	9	7	Specialist and Non-routine Eye Exam	01	7d;17a;		2		2			1	45.00	45.00	2	
H3916	012	0	1	04	01	H3916_012_0	9	8	End Stage Renal Disease	01	12;		2		1	20	30	2			2	
H3916	012	0	1	04	01	H3916_012_0	9	9	Medicare Part B Rx Drugs	01	15;		2		1	30	30	2			2	
H3916	015	0	1	04	01	H3916_015_0	10	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;16b;18a;	7b;7f;9d;18a;	2		1	30	30	2			2	
H3916	015	0	1	04	01	H3916_015_0	10	10	Routine Eye Exams	10		17a;	2		2			1	50.00	50.00	2	
H3916	015	0	1	04	01	H3916_015_0	10	11	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H3916	015	0	1	04	01	H3916_015_0	10	2	Preventive Services and Routine Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2			2	
H3916	015	0	1	04	01	H3916_015_0	10	3	Ambulance	01	10a;		2		1	30	30	1	175.00	175.00	2	
H3916	015	0	1	04	01	H3916_015_0	10	4	Transportation and Preventive Dental	10		10b;16a;	2		1	50	50	2			2	
H3916	015	0	1	04	01	H3916_015_0	10	5	Fitness Benefit	10		14c;	2		1	50	50	2			1	500.00
H3916	015	0	1	04	01	H3916_015_0	10	6	Primary Care Physician	01	7a;		2		2			1	30.00	30.00	2	
H3916	015	0	1	04	01	H3916_015_0	10	7	Specialist and Non-routine Eye Exam	01	7d;17a;		2		2			1	45.00	45.00	2	
H3916	015	0	1	04	01	H3916_015_0	10	8	End Stage Renal Disease	01	12;		2		1	20	30	2			2	
H3916	015	0	1	04	01	H3916_015_0	10	9	Medicare Part B Rx Drugs	01	15;		2		1	30	30	2			2	
H3916	018	0	1	04	01	H3916_018_0	10	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;16b;18a;	7b;7f;9d;18a;	2		1	30	30	2			2	
H3916	018	0	1	04	01	H3916_018_0	10	10	Routine Eye Exams	10		17a;	2		2			1	50.00	50.00	2	
H3916	018	0	1	04	01	H3916_018_0	10	11	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H3916	018	0	1	04	01	H3916_018_0	10	2	Preventive Services and Routine Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2			2	
H3916	018	0	1	04	01	H3916_018_0	10	3	Ambulance	01	10a;		2		1	30	30	1	200.00	200.00	2	
H3916	018	0	1	04	01	H3916_018_0	10	4	Transportation and Preventive Dental	10		10b;16a;	2		1	50	50	2			2	
H3916	018	0	1	04	01	H3916_018_0	10	5	Fitness Benefit	10		14c;	2		1	50	50	2			1	500.00
H3916	018	0	1	04	01	H3916_018_0	10	6	Primary Care Physician	01	7a;		2		2			1	30.00	30.00	2	
H3916	018	0	1	04	01	H3916_018_0	10	7	Specialist and Non-routine Eye Exam	01	7d;17a;		2		2			1	50.00	50.00	2	
H3916	018	0	1	04	01	H3916_018_0	10	8	End Stage Renal Disease	01	12;		2		1	20	30	2			2	
H3916	018	0	1	04	01	H3916_018_0	10	9	Medicare Part B Rx Drugs	01	15;		2		1	30	30	2			2	
H3916	022	0	1	04	01	H3916_022_0	10	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;16b;18a;	7b;7f;9d;18a;	2		1	30	30	2			2	
H3916	022	0	1	04	01	H3916_022_0	10	10	Routine Eye Exams	10		17a;	2		2			1	50.00	50.00	2	
H3916	022	0	1	04	01	H3916_022_0	10	11	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H3916	022	0	1	04	01	H3916_022_0	10	2	Preventive Services and Routine Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2			2	
H3916	022	0	1	04	01	H3916_022_0	10	3	Ambulance	01	10a;		2		1	30	30	1	175.00	175.00	2	
H3916	022	0	1	04	01	H3916_022_0	10	4	Transportation and Preventive Dental	10		10b;16a;	2		1	50	50	2			2	
H3916	022	0	1	04	01	H3916_022_0	10	5	Fitness Benefit	10		14c;	2		1	50	50	2			1	500.00
H3916	022	0	1	04	01	H3916_022_0	10	6	Primary Care Physician	01	7a;		2		2			1	15.00	15.00	2	
H3916	022	0	1	04	01	H3916_022_0	10	7	Specialist and Non-routine Eye Exam	01	7d;17a;		2		2			1	40.00	40.00	2	
H3916	022	0	1	04	01	H3916_022_0	10	8	End Stage Renal Disease	01	12;		2		1	20	30	2			2	
H3916	022	0	1	04	01	H3916_022_0	10	9	Medicare Part B Rx Drugs	01	15;		2		1	30	30	2			2	
H3916	024	0	1	04	01	H3916_024_0	11	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;16b;18a;	7b;7f;9d;18a;	2		1	30	30	2			2	
H3916	024	0	1	04	01	H3916_024_0	11	10	Routine Eye Exams	10		17a;	2		2			1	50.00	50.00	2	
H3916	024	0	1	04	01	H3916_024_0	11	11	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H3916	024	0	1	04	01	H3916_024_0	11	2	Preventive Services and Routine Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2			2	
H3916	024	0	1	04	01	H3916_024_0	11	3	Ambulance	01	10a;		2		1	30	30	1	175.00	175.00	2	
H3916	024	0	1	04	01	H3916_024_0	11	4	Transportation and Preventive Dental	10		10b;16a;	2		1	50	50	2			2	
H3916	024	0	1	04	01	H3916_024_0	11	5	Fitness Benefit	10		14c;	2		1	50	50	2			1	500.00
H3916	024	0	1	04	01	H3916_024_0	11	6	Primary Care Physician	01	7a;		2		2			1	15.00	15.00	2	
H3916	024	0	1	04	01	H3916_024_0	11	7	Specialist and Non-routine Eye Exam	01	7d;17a;		2		2			1	40.00	40.00	2	
H3916	024	0	1	04	01	H3916_024_0	11	8	End Stage Renal Disease	01	12;		2		1	20	30	2			2	
H3916	024	0	1	04	01	H3916_024_0	11	9	Medicare Part B Rx Drugs	01	15;		2		1	30	30	2			2	
H3916	032	0	1	04	01	H3916_032_0	10	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;16b;18a;	7b;7f;9d;18a;	2		1	30	30	2			2	
H3916	032	0	1	04	01	H3916_032_0	10	10	Routine Eye Exams	10		17a;	2		2			1	50.00	50.00	2	
H3916	032	0	1	04	01	H3916_032_0	10	11	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H3916	032	0	1	04	01	H3916_032_0	10	2	Preventive Services and Routine Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2			2	
H3916	032	0	1	04	01	H3916_032_0	10	3	Ambulance	01	10a;		2		1	30	30	1	225.00	225.00	2	
H3916	032	0	1	04	01	H3916_032_0	10	4	Transportation and Preventive Dental	10		10b;16a;	2		1	50	50	2			2	
H3916	032	0	1	04	01	H3916_032_0	10	5	Fitness Benefit	10		14c;	2		1	50	50	2			1	500.00
H3916	032	0	1	04	01	H3916_032_0	10	6	Primary Care Physician	01	7a;		2		2			1	20.00	20.00	2	
H3916	032	0	1	04	01	H3916_032_0	10	7	Specialist and Non-routine Eye Exam	01	7d;17a;		2		2			1	50.00	50.00	2	
H3916	032	0	1	04	01	H3916_032_0	10	8	End Stage Renal Disease	01	12;		2		1	20	30	2			2	
H3916	032	0	1	04	01	H3916_032_0	10	9	Medicare Part B Rx Drugs	01	15;		2		1	30	30	2			2	
H3916	033	0	1	04	01	H3916_033_0	11	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;16b;18a;	7b;7f;9d;18a;	2		1	30	30	2			2	
H3916	033	0	1	04	01	H3916_033_0	11	10	Routine Eye Exams	10		17a;	2		2			1	50.00	50.00	2	
H3916	033	0	1	04	01	H3916_033_0	11	11	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H3916	033	0	1	04	01	H3916_033_0	11	2	Preventive Services and Routine Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2			2	
H3916	033	0	1	04	01	H3916_033_0	11	3	Ambulance	01	10a;		2		1	30	30	1	225.00	225.00	2	
H3916	033	0	1	04	01	H3916_033_0	11	4	Transportation and Preventive Dental	10		10b;16a;	2		1	50	50	2			2	
H3916	033	0	1	04	01	H3916_033_0	11	5	Fitness Benefit	10		14c;	2		1	50	50	2			1	500.00
H3916	033	0	1	04	01	H3916_033_0	11	6	Primary Care Physician	01	7a;		2		2			1	20.00	20.00	2	
H3916	033	0	1	04	01	H3916_033_0	11	7	Specialist and Non-routine Eye Exam	01	7d;17a;		2		2			1	50.00	50.00	2	
H3916	033	0	1	04	01	H3916_033_0	11	8	End Stage Renal Disease	01	12;		2		1	20	30	2			2	
H3916	033	0	1	04	01	H3916_033_0	11	9	Medicare Part B Rx Drugs	01	15;		2		1	30	30	2			2	
H3916	034	1	1	04	01	H3916_034_1	10	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;9c;9d;11a;11b;11c;15;16b;18a;	7b;7f;9d;18a;	2		1	30	30	2			2	
H3916	034	1	1	04	01	H3916_034_1	10	10	Diagnostic Procedures/Tests and Lab Serv	01	8a1;8a2;		2		2			1	40.00	40.00	2	
H3916	034	1	1	04	01	H3916_034_1	10	11	Diagnostic Radiological Services	01	8b1;		2		2			1	370.00	370.00	2	
H3916	034	1	1	04	01	H3916_034_1	10	12	Therapeutic Radiological Services	01	8b2;		2		2			1	90.00	90.00	2	
H3916	034	1	1	04	01	H3916_034_1	10	13	Outpatient X-Ray Services	01	8b3;		2		2			1	70.00	70.00	2	
H3916	034	1	1	04	01	H3916_034_1	10	14	Outpatient Hospital Services/ASC Service	01	9a;9b;		2		2			1	450.00	450.00	2	
H3916	034	1	1	04	01	H3916_034_1	10	15	Routine Eye Exams	10		17a;	2		2			1	50.00	50.00	2	
H3916	034	1	1	04	01	H3916_034_1	10	2	Preventive Services and Routine Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2			2	
H3916	034	1	1	04	01	H3916_034_1	10	3	Ambulance	01	10a;		2		1	30	30	1	350.00	350.00	2	
H3916	034	1	1	04	01	H3916_034_1	10	4	Transportation and Preventive Dental	10		10b;16a;	2		1	50	50	2			2	
H3916	034	1	1	04	01	H3916_034_1	10	5	Fitness Benefit	10		14c;	2		1	50	50	2			1	500.00
H3916	034	1	1	04	01	H3916_034_1	10	6	Primary Care Physician	01	7a;		2		2			1	25.00	25.00	2	
H3916	034	1	1	04	01	H3916_034_1	10	7	Specialist and Non-routine Eye Exam	01	7d;17a;		2		2			1	60.00	60.00	2	
H3916	034	1	1	04	01	H3916_034_1	10	8	End Stage Renal Disease	01	12;		2		1	20	30	2			2	
H3916	034	1	1	04	01	H3916_034_1	10	9	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H3916	034	3	1	04	01	H3916_034_3	10	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;9c;9d;11a;11b;11c;15;16b;18a;	7b;7f;9d;18a;	2		1	30	30	2			2	
H3916	034	3	1	04	01	H3916_034_3	10	10	Diagnostic Procedures/Tests and Lab Serv	01	8a1;8a2;		2		2			1	40.00	40.00	2	
H3916	034	3	1	04	01	H3916_034_3	10	11	Diagnostic Radiological Services	01	8b1;		2		2			1	370.00	370.00	2	
H3916	034	3	1	04	01	H3916_034_3	10	12	Therapeutic Radiological Services	01	8b2;		2		2			1	90.00	90.00	2	
H3916	034	3	1	04	01	H3916_034_3	10	13	Outpatient X-Ray Services	01	8b3;		2		2			1	70.00	70.00	2	
H3916	034	3	1	04	01	H3916_034_3	10	14	Outpatient Hospital Services/ASC Service	01	9a;9b;		2		2			1	450.00	450.00	2	
H3916	034	3	1	04	01	H3916_034_3	10	15	Routine Eye Exams	10		17a;	2		2			1	50.00	50.00	2	
H3916	034	3	1	04	01	H3916_034_3	10	2	Preventive Services and Routine Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2			2	
H3916	034	3	1	04	01	H3916_034_3	10	3	Ambulance	01	10a;		2		1	30	30	1	350.00	350.00	2	
H3916	034	3	1	04	01	H3916_034_3	10	4	Transportation and Preventive Dental	10		10b;16a;	2		1	50	50	2			2	
H3916	034	3	1	04	01	H3916_034_3	10	5	Fitness Benefit	10		14c;	2		1	50	50	2			1	500.00
H3916	034	3	1	04	01	H3916_034_3	10	6	Primary Care Physician	01	7a;		2		2			1	25.00	25.00	2	
H3916	034	3	1	04	01	H3916_034_3	10	7	Specialist and Non-routine Eye Exam	01	7d;17a;		2		2			1	60.00	60.00	2	
H3916	034	3	1	04	01	H3916_034_3	10	8	End Stage Renal Disease	01	12;		2		1	20	30	2			2	
H3916	034	3	1	04	01	H3916_034_3	10	9	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H3916	034	4	1	04	01	H3916_034_4	10	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;9c;9d;11a;11b;11c;15;16b;18a;	7b;7f;9d;18a;	2		1	30	30	2			2	
H3916	034	4	1	04	01	H3916_034_4	10	10	Diagnostic Procedures/Tests and Lab Serv	01	8a1;8a2;		2		2			1	40.00	40.00	2	
H3916	034	4	1	04	01	H3916_034_4	10	11	Diagnostic Radiological Services	01	8b1;		2		2			1	370.00	370.00	2	
H3916	034	4	1	04	01	H3916_034_4	10	12	Therapeutic Radiological Services	01	8b2;		2		2			1	90.00	90.00	2	
H3916	034	4	1	04	01	H3916_034_4	10	13	Outpatient X-Ray Services	01	8b3;		2		2			1	70.00	70.00	2	
H3916	034	4	1	04	01	H3916_034_4	10	14	Outpatient Hospital Services/ASC Service	01	9a;9b;		2		2			1	450.00	450.00	2	
H3916	034	4	1	04	01	H3916_034_4	10	15	Routine Eye Exams	10		17a;	2		2			1	50.00	50.00	2	
H3916	034	4	1	04	01	H3916_034_4	10	2	Preventive Services and Routine Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2			2	
H3916	034	4	1	04	01	H3916_034_4	10	3	Ambulance	01	10a;		2		1	30	30	1	350.00	350.00	2	
H3916	034	4	1	04	01	H3916_034_4	10	4	Transportation and Preventive Dental	10		10b;16a;	2		1	50	50	2			2	
H3916	034	4	1	04	01	H3916_034_4	10	5	Fitness Benefit	10		14c;	2		1	50	50	2			1	500.00
H3916	034	4	1	04	01	H3916_034_4	10	6	Primary Care Physician	01	7a;		2		2			1	25.00	25.00	2	
H3916	034	4	1	04	01	H3916_034_4	10	7	Specialist and Non-routine Eye Exam	01	7d;17a;		2		2			1	60.00	60.00	2	
H3916	034	4	1	04	01	H3916_034_4	10	8	End Stage Renal Disease	01	12;		2		1	20	30	2			2	
H3916	034	4	1	04	01	H3916_034_4	10	9	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H3916	035	1	1	04	01	H3916_035_1	10	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;9c;9d;11a;11b;11c;15;16b;18a;	7b;7f;9d;18a;	2		1	30	30	2			2	
H3916	035	1	1	04	01	H3916_035_1	10	10	Diagnostic Procedures/Tests and Lab Serv	01	8a1;8a2;		2		2			1	35.00	35.00	2	
H3916	035	1	1	04	01	H3916_035_1	10	11	Diagnostic Radiological Services	01	8b1;		2		2			1	370.00	370.00	2	
H3916	035	1	1	04	01	H3916_035_1	10	12	Therapeutic Radiological Services	01	8b2;		2		2			1	90.00	90.00	2	
H3916	035	1	1	04	01	H3916_035_1	10	13	Outpatient X-Ray Services	01	8b3;		2		2			1	70.00	70.00	2	
H3916	035	1	1	04	01	H3916_035_1	10	14	Outpatient Hospital Services/ASC Service	01	9a;9b;		2		2			1	450.00	450.00	2	
H3916	035	1	1	04	01	H3916_035_1	10	15	Routine Eye Exams	10		17a;	2		2			1	50.00	50.00	2	
H3916	035	1	1	04	01	H3916_035_1	10	2	Preventive Services and Routine Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2			2	
H3916	035	1	1	04	01	H3916_035_1	10	3	Ambulance	01	10a;		2		1	30	30	1	350.00	350.00	2	
H3916	035	1	1	04	01	H3916_035_1	10	4	Transportation and Preventive Dental	10		10b;16a;	2		1	50	50	2			2	
H3916	035	1	1	04	01	H3916_035_1	10	5	Fitness Benefit	10		14c;	2		1	50	50	2			1	500.00
H3916	035	1	1	04	01	H3916_035_1	10	6	Primary Care Physician	01	7a;		2		2			1	25.00	25.00	2	
H3916	035	1	1	04	01	H3916_035_1	10	7	Specialist and Non-routine Eye Exam	01	7d;17a;		2		2			1	60.00	60.00	2	
H3916	035	1	1	04	01	H3916_035_1	10	8	End Stage Renal Disease	01	12;		2		1	20	30	2			2	
H3916	035	1	1	04	01	H3916_035_1	10	9	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H3916	035	2	1	04	01	H3916_035_2	10	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;9c;9d;11a;11b;11c;15;16b;18a;	7b;7f;9d;18a;	2		1	30	30	2			2	
H3916	035	2	1	04	01	H3916_035_2	10	10	Diagnostic Procedures/Tests and Lab Serv	01	8a1;8a2;		2		2			1	35.00	35.00	2	
H3916	035	2	1	04	01	H3916_035_2	10	11	Diagnostic Radiological Services	01	8b1;		2		2			1	370.00	370.00	2	
H3916	035	2	1	04	01	H3916_035_2	10	12	Therapeutic Radiological Services	01	8b2;		2		2			1	90.00	90.00	2	
H3916	035	2	1	04	01	H3916_035_2	10	13	Outpatient X-Ray Services	01	8b3;		2		2			1	70.00	70.00	2	
H3916	035	2	1	04	01	H3916_035_2	10	14	Outpatient Hospital Services/ASC Service	01	9a;9b;		2		2			1	450.00	450.00	2	
H3916	035	2	1	04	01	H3916_035_2	10	15	Routine Eye Exams	10		17a;	2		2			1	50.00	50.00	2	
H3916	035	2	1	04	01	H3916_035_2	10	2	Preventive Services and Routine Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2			2	
H3916	035	2	1	04	01	H3916_035_2	10	3	Ambulance	01	10a;		2		1	30	30	1	350.00	350.00	2	
H3916	035	2	1	04	01	H3916_035_2	10	4	Transportation and Preventive Dental	10		10b;16a;	2		1	50	50	2			2	
H3916	035	2	1	04	01	H3916_035_2	10	5	Fitness Benefit	10		14c;	2		1	50	50	2			1	500.00
H3916	035	2	1	04	01	H3916_035_2	10	6	Primary Care Physician	01	7a;		2		2			1	25.00	25.00	2	
H3916	035	2	1	04	01	H3916_035_2	10	7	Specialist and Non-routine Eye Exam	01	7d;17a;		2		2			1	60.00	60.00	2	
H3916	035	2	1	04	01	H3916_035_2	10	8	End Stage Renal Disease	01	12;		2		1	20	30	2			2	
H3916	035	2	1	04	01	H3916_035_2	10	9	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H3916	036	0	1	04	01	H3916_036_0	11	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;9c;9d;11a;11b;11c;15;16b;18a;	7b;7f;9d;18a;	2		1	30	30	2			2	
H3916	036	0	1	04	01	H3916_036_0	11	10	Diagnostic Procedures/Tests and Lab Serv	01	8a1;8a2;		2		2			1	40.00	40.00	2	
H3916	036	0	1	04	01	H3916_036_0	11	11	Diagnostic Radiological Services	01	8b1;		2		2			1	370.00	370.00	2	
H3916	036	0	1	04	01	H3916_036_0	11	12	Therapeutic Radiological Services	01	8b2;		2		2			1	90.00	90.00	2	
H3916	036	0	1	04	01	H3916_036_0	11	13	Outpatient X-Ray Services	01	8b3;		2		2			1	70.00	70.00	2	
H3916	036	0	1	04	01	H3916_036_0	11	14	Outpatient Hospital Services/ASC Service	01	9a;9b;		2		2			1	450.00	450.00	2	
H3916	036	0	1	04	01	H3916_036_0	11	15	Routine Eye Exams	10		17a;	2		2			1	50.00	50.00	2	
H3916	036	0	1	04	01	H3916_036_0	11	2	Preventive Services and Routine Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2			2	
H3916	036	0	1	04	01	H3916_036_0	11	3	Ambulance	01	10a;		2		1	30	30	1	350.00	350.00	2	
H3916	036	0	1	04	01	H3916_036_0	11	4	Transportation and Preventive Dental	10		10b;16a;	2		1	50	50	2			2	
H3916	036	0	1	04	01	H3916_036_0	11	5	Fitness Benefit	10		14c;	2		1	50	50	2			1	500.00
H3916	036	0	1	04	01	H3916_036_0	11	6	Primary Care Physician	01	7a;		2		2			1	25.00	25.00	2	
H3916	036	0	1	04	01	H3916_036_0	11	7	Specialist and Non-routine Eye Exam	01	7d;17a;		2		2			1	60.00	60.00	2	
H3916	036	0	1	04	01	H3916_036_0	11	8	End Stage Renal Disease	01	12;		2		1	20	30	2			2	
H3916	036	0	1	04	01	H3916_036_0	11	9	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H3916	801	0	1	04	01	H3916_801_0	8	1		01	6;14a;		2		1	0	0	2			2	
H3916	801	0	1	04	01	H3916_801_0	8	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3916	802	0	1	04	01	H3916_802_0	8	1		01	6;14a;		2		1	0	0	2			2	
H3916	802	0	1	04	01	H3916_802_0	8	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3916	804	0	1	04	01	H3916_804_0	8	1		01	6;14a;		2		1	0	0	2			2	
H3916	804	0	1	04	01	H3916_804_0	8	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3916	805	0	1	04	01	H3916_805_0	8	1		01	6;14a;		2		1	0	0	2			2	
H3916	805	0	1	04	01	H3916_805_0	8	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3916	806	0	1	04	01	H3916_806_0	8	1		01	6;14a;		2		1	0	0	2			2	
H3916	806	0	1	04	01	H3916_806_0	8	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3916	807	0	1	04	01	H3916_807_0	8	1		01	6;14a;		2		1	0	0	2			2	
H3916	807	0	1	04	01	H3916_807_0	8	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3923	013	0	1	04	01	H3923_013_0	7	1	OON Medical Benefits	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;	2		1	30	30	2			2	
H3923	013	0	1	04	01	H3923_013_0	7	2	OON Routine Hearing Eye Exams and Dental	10		16a;16b;17a;18a;	2		1	50	50	2			2	
H3923	013	0	1	04	01	H3923_013_0	7	3	OON OTC	10		13b;	1	15.00	2			2			2	
H3923	013	0	1	04	01	H3923_013_0	7	4	OON Ambulance	01	10a;		2		2			1	150.00	150.00	2	
H3923	013	0	1	04	01	H3923_013_0	7	5	OON Supplement Benefits	10		14c;	2		1	0	50	2			2	
H3923	013	0	1	04	01	H3923_013_0	7	6	OON Routine Eyewear and Hearing Aids	10		17b;18b;	2		2			2			2	
H3923	017	0	1	04	01	H3923_017_0	7	1	OON Medical Benefits	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;	2		1	30	30	2			2	
H3923	017	0	1	04	01	H3923_017_0	7	2	OON Routine Hearing Eye Exams and Dental	10		16a;16b;17a;18a;	2		1	50	50	2			2	
H3923	017	0	1	04	01	H3923_017_0	7	3	OON Ambulance	01	10a;		2		2			1	125.00	125.00	2	
H3923	017	0	1	04	01	H3923_017_0	7	4	OON OTC	10		13b;	1	15.00	2			2			2	
H3923	017	0	1	04	01	H3923_017_0	7	5	OON Supplemental Benefits	10		14c;	2		1	0	50	2			2	
H3923	017	0	1	04	01	H3923_017_0	7	6	OON Eyewear and Hearing Aids	10		17b;18b;	2		2			2			2	
H3923	801	0	1	04	01	H3923_801_0	3	1		01	6;14a;		2		1	0	0	2			2	
H3923	801	0	1	04	01	H3923_801_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3923	802	0	1	04	01	H3923_802_0	3	1		01	6;14a;		2		1	0	0	2			2	
H3923	802	0	1	04	01	H3923_802_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3923	803	0	1	04	01	H3923_803_0	3	1		01	6;14a;		2		1	0	0	2			2	
H3923	803	0	1	04	01	H3923_803_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H3924	059	3	1	04	01	H3924_059_3	5	1	Out of Network $0 benefits	10		14c;	1	90.00	2			2			2	
H3924	059	3	1	04	01	H3924_059_3	5	10	Outpatient Surgery and ASC	01	9a;9b;		2		2			1	225.00	225.00	2	
H3924	059	3	1	04	01	H3924_059_3	5	11	20% Coinsurance Benefits	01	11a;11b;12;15;		2		1	20	20	2			2	
H3924	059	3	1	04	01	H3924_059_3	5	12	Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H3924	059	3	1	04	01	H3924_059_3	5	13	Diagnostic Radiological Services	01	8b1;		2		2			1	25.00	200.00	2	
H3924	059	3	1	04	01	H3924_059_3	5	14	Therapeutic Radiation Services	01	8b2;		2		2			1	25.00	60.00	2	
H3924	059	3	1	04	01	H3924_059_3	5	2	Out of Network $0 Copay	11	3-1;3-2;3-3;6;7g;9d;14a;14d;14e;17b;	7f;	2		2			2			2	
H3924	059	3	1	04	01	H3924_059_3	5	3	$5 Copay PCP and Annual Routine Physical	11	7a;	14b;	2		2			1	5.00	5.00	2	
H3924	059	3	1	04	01	H3924_059_3	5	4	Diagnostic Procedures, Tests and Lab	01	8a1;8a2;		2		2			1	15.00	15.00	2	
H3924	059	3	1	04	01	H3924_059_3	5	5	Mental Health, Psych, Substance Abuse	01	7e;7h;9c;		2		2			1	10.00	25.00	2	
H3924	059	3	1	04	01	H3924_059_3	5	6	$20 Copayment	01	7b;		2		2			1	20.00	20.00	2	
H3924	059	3	1	04	01	H3924_059_3	5	7	Specialist Copayment and X-rays	01	7c;7d;7f;7i;8b3;16b;17a;18a;		2		2			1	25.00	25.00	2	
H3924	059	3	1	04	01	H3924_059_3	5	8	Partial Hospitalization	01	5;		2		2			1	55.00	55.00	2	
H3924	059	3	1	04	01	H3924_059_3	5	9	Ambulance	01	10a;		2		2			1	200.00	200.00	2	
H3924	059	4	1	04	01	H3924_059_4	5	1	Out of Network $0 benefits	10		14c;	1	90.00	2			2			2	
H3924	059	4	1	04	01	H3924_059_4	5	10	Outpatient Surgery and ASC	01	9a;9b;		2		2			1	225.00	225.00	2	
H3924	059	4	1	04	01	H3924_059_4	5	11	20% Coinsurance Benefits	01	11a;11b;12;15;		2		1	20	20	2			2	
H3924	059	4	1	04	01	H3924_059_4	5	12	Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H3924	059	4	1	04	01	H3924_059_4	5	13	Diagnostic Radiological Services	01	8b1;		2		2			1	25.00	200.00	2	
H3924	059	4	1	04	01	H3924_059_4	5	14	Therapeutic Radiation Services	01	8b2;		2		2			1	25.00	60.00	2	
H3924	059	4	1	04	01	H3924_059_4	5	2	Out of Network $0 Copay	11	3-1;3-2;3-3;6;7g;9d;14a;14d;14e;17b;	7f;	2		2			2			2	
H3924	059	4	1	04	01	H3924_059_4	5	3	$5 Copay PCP and Annual Routine Physical	11	7a;	14b;	2		2			1	5.00	5.00	2	
H3924	059	4	1	04	01	H3924_059_4	5	4	Diagnostic Procedures, Tests and Lab	01	8a1;8a2;		2		2			1	15.00	15.00	2	
H3924	059	4	1	04	01	H3924_059_4	5	5	Mental Health, Psych, Substance Abuse	01	7e;7h;9c;		2		2			1	10.00	25.00	2	
H3924	059	4	1	04	01	H3924_059_4	5	6	$20 Copayment	01	7b;		2		2			1	20.00	20.00	2	
H3924	059	4	1	04	01	H3924_059_4	5	7	Specialist Copayment and X-rays	01	7c;7d;7f;7i;8b3;16b;17a;18a;		2		2			1	25.00	25.00	2	
H3924	059	4	1	04	01	H3924_059_4	5	8	Partial Hospitalization	01	5;		2		2			1	55.00	55.00	2	
H3924	059	4	1	04	01	H3924_059_4	5	9	Ambulance	01	10a;		2		2			1	200.00	200.00	2	
H3924	059	6	1	04	01	H3924_059_6	5	1	Out of Network $0 benefits	10		14c;	1	90.00	2			2			2	
H3924	059	6	1	04	01	H3924_059_6	5	10	Outpatient Surgery and ASC	01	9a;9b;		2		2			1	225.00	225.00	2	
H3924	059	6	1	04	01	H3924_059_6	5	11	20% Coinsurance Benefits	01	11a;11b;12;15;		2		1	20	20	2			2	
H3924	059	6	1	04	01	H3924_059_6	5	12	Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H3924	059	6	1	04	01	H3924_059_6	5	13	Diagnostic Radiological Services	01	8b1;		2		2			1	25.00	200.00	2	
H3924	059	6	1	04	01	H3924_059_6	5	14	Therapeutic Radiation Services	01	8b2;		2		2			1	25.00	60.00	2	
H3924	059	6	1	04	01	H3924_059_6	5	2	Out of Network $0 Copay	11	3-1;3-2;3-3;6;7g;9d;14a;14d;14e;17b;	7f;	2		2			2			2	
H3924	059	6	1	04	01	H3924_059_6	5	3	$5 Copay PCP and Annual Routine Physical	11	7a;	14b;	2		2			1	5.00	5.00	2	
H3924	059	6	1	04	01	H3924_059_6	5	4	Diagnostic Procedures, Tests and Lab	01	8a1;8a2;		2		2			1	15.00	15.00	2	
H3924	059	6	1	04	01	H3924_059_6	5	5	Mental Health, Psych, Substance Abuse	01	7e;7h;9c;		2		2			1	10.00	25.00	2	
H3924	059	6	1	04	01	H3924_059_6	5	6	$20 Copayment	01	7b;		2		2			1	20.00	20.00	2	
H3924	059	6	1	04	01	H3924_059_6	5	7	Specialist Copayment and X-rays	01	7c;7d;7f;7i;8b3;16b;17a;18a;		2		2			1	25.00	25.00	2	
H3924	059	6	1	04	01	H3924_059_6	5	8	Partial Hospitalization	01	5;		2		2			1	55.00	55.00	2	
H3924	059	6	1	04	01	H3924_059_6	5	9	Ambulance	01	10a;		2		2			1	200.00	200.00	2	
H3924	059	7	1	04	01	H3924_059_7	5	1	Out of Network $0 benefits	10		14c;	1	90.00	2			2			2	
H3924	059	7	1	04	01	H3924_059_7	5	10	Outpatient Surgery and ASC	01	9a;9b;		2		2			1	225.00	225.00	2	
H3924	059	7	1	04	01	H3924_059_7	5	11	20% Coinsurance Benefits	01	11a;11b;12;15;		2		1	20	20	2			2	
H3924	059	7	1	04	01	H3924_059_7	5	12	Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H3924	059	7	1	04	01	H3924_059_7	5	13	Diagnostic Radiological Services	01	8b1;		2		2			1	25.00	200.00	2	
H3924	059	7	1	04	01	H3924_059_7	5	14	Therapeutic Radiation Services	01	8b2;		2		2			1	25.00	60.00	2	
H3924	059	7	1	04	01	H3924_059_7	5	2	Out of Network $0 Copay	11	3-1;3-2;3-3;6;7g;9d;14a;14d;14e;17b;	7f;	2		2			2			2	
H3924	059	7	1	04	01	H3924_059_7	5	3	$5 Copay PCP and Annual Routine Physical	11	7a;	14b;	2		2			1	5.00	5.00	2	
H3924	059	7	1	04	01	H3924_059_7	5	4	Diagnostic Procedures, Tests and Lab	01	8a1;8a2;		2		2			1	15.00	15.00	2	
H3924	059	7	1	04	01	H3924_059_7	5	5	Mental Health, Psych, Substance Abuse	01	7e;7h;9c;		2		2			1	10.00	25.00	2	
H3924	059	7	1	04	01	H3924_059_7	5	6	$20 Copayment	01	7b;		2		2			1	20.00	20.00	2	
H3924	059	7	1	04	01	H3924_059_7	5	7	Specialist Copayment and X-rays	01	7c;7d;7f;7i;8b3;16b;17a;18a;		2		2			1	25.00	25.00	2	
H3924	059	7	1	04	01	H3924_059_7	5	8	Partial Hospitalization	01	5;		2		2			1	55.00	55.00	2	
H3924	059	7	1	04	01	H3924_059_7	5	9	Ambulance	01	10a;		2		2			1	200.00	200.00	2	
H3924	059	8	1	04	01	H3924_059_8	5	1	Out of Network $0 benefits	10		14c;	1	90.00	2			2			2	
H3924	059	8	1	04	01	H3924_059_8	5	10	Outpatient Surgery and ASC	01	9a;9b;		2		2			1	225.00	225.00	2	
H3924	059	8	1	04	01	H3924_059_8	5	11	20% Coinsurance Benefits	01	11a;11b;12;15;		2		1	20	20	2			2	
H3924	059	8	1	04	01	H3924_059_8	5	12	Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H3924	059	8	1	04	01	H3924_059_8	5	13	Diagnostic Radiological Services	01	8b1;		2		2			1	25.00	200.00	2	
H3924	059	8	1	04	01	H3924_059_8	5	14	Therapeutic Radiation Services	01	8b2;		2		2			1	25.00	60.00	2	
H3924	059	8	1	04	01	H3924_059_8	5	2	Out of Network $0 Copay	11	3-1;3-2;3-3;6;7g;9d;14a;14d;14e;17b;	7f;	2		2			2			2	
H3924	059	8	1	04	01	H3924_059_8	5	3	$5 Copay PCP and Annual Routine Physical	11	7a;	14b;	2		2			1	5.00	5.00	2	
H3924	059	8	1	04	01	H3924_059_8	5	4	Diagnostic Procedures, Tests and Lab	01	8a1;8a2;		2		2			1	15.00	15.00	2	
H3924	059	8	1	04	01	H3924_059_8	5	5	Mental Health, Psych, Substance Abuse	01	7e;7h;9c;		2		2			1	10.00	25.00	2	
H3924	059	8	1	04	01	H3924_059_8	5	6	$20 Copayment	01	7b;		2		2			1	20.00	20.00	2	
H3924	059	8	1	04	01	H3924_059_8	5	7	Specialist Copayment and X-rays	01	7c;7d;7f;7i;8b3;16b;17a;18a;		2		2			1	25.00	25.00	2	
H3924	059	8	1	04	01	H3924_059_8	5	8	Partial Hospitalization	01	5;		2		2			1	55.00	55.00	2	
H3924	059	8	1	04	01	H3924_059_8	5	9	Ambulance	01	10a;		2		2			1	200.00	200.00	2	
H3924	059	9	1	04	01	H3924_059_9	5	1	Out of Network $0 benefits	10		14c;	1	90.00	2			2			2	
H3924	059	9	1	04	01	H3924_059_9	5	10	Outpatient Surgery and ASC	01	9a;9b;		2		2			1	225.00	225.00	2	
H3924	059	9	1	04	01	H3924_059_9	5	11	20% Coinsurance Benefits	01	11a;11b;12;15;		2		1	20	20	2			2	
H3924	059	9	1	04	01	H3924_059_9	5	12	Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H3924	059	9	1	04	01	H3924_059_9	5	13	Diagnostic Radiological Services	01	8b1;		2		2			1	25.00	200.00	2	
H3924	059	9	1	04	01	H3924_059_9	5	14	Therapeutic Radiation Services	01	8b2;		2		2			1	25.00	60.00	2	
H3924	059	9	1	04	01	H3924_059_9	5	2	Out of Network $0 Copay	11	3-1;3-2;3-3;6;7g;9d;14a;14d;14e;17b;	7f;	2		2			2			2	
H3924	059	9	1	04	01	H3924_059_9	5	3	$5 Copay PCP and Annual Routine Physical	11	7a;	14b;	2		2			1	5.00	5.00	2	
H3924	059	9	1	04	01	H3924_059_9	5	4	Diagnostic Procedures, Tests and Lab	01	8a1;8a2;		2		2			1	15.00	15.00	2	
H3924	059	9	1	04	01	H3924_059_9	5	5	Mental Health, Psych, Substance Abuse	01	7e;7h;9c;		2		2			1	10.00	25.00	2	
H3924	059	9	1	04	01	H3924_059_9	5	6	$20 Copayment	01	7b;		2		2			1	20.00	20.00	2	
H3924	059	9	1	04	01	H3924_059_9	5	7	Specialist Copayment and X-rays	01	7c;7d;7f;7i;8b3;16b;17a;18a;		2		2			1	25.00	25.00	2	
H3924	059	9	1	04	01	H3924_059_9	5	8	Partial Hospitalization	01	5;		2		2			1	55.00	55.00	2	
H3924	059	9	1	04	01	H3924_059_9	5	9	Ambulance	01	10a;		2		2			1	200.00	200.00	2	
H3924	060	3	1	04	01	H3924_060_3	5	1	Out of Network $0 Copay Benefits	11	3-1;3-2;3-3;6;7g;9d;14a;14d;14e;17b;	7f;	2		2			2			2	
H3924	060	3	1	04	01	H3924_060_3	5	10	$20 copayment	01	7b;		2		2			1	20.00	20.00	2	
H3924	060	3	1	04	01	H3924_060_3	5	11	Mental health/sub abuse	01	7e;7h;9c;		2		2			1	10.00	25.00	2	
H3924	060	3	1	04	01	H3924_060_3	5	12	$30 Diagnostic Procedures, Tests and Lab	01	8a1;8a2;		2		2			1	30.00	30.00	2	
H3924	060	3	1	04	01	H3924_060_3	5	13	Diagnostic radiology	01	8b1;8b3;		2		2			1	40.00	275.00	2	
H3924	060	3	1	04	01	H3924_060_3	5	14	Therapeutic radiology	01	8b2;		2		2			1	40.00	60.00	2	
H3924	060	3	1	04	01	H3924_060_3	5	2	Medicare benefits with a 20% coinsurance	01	11a;11b;12;15;		2		1	20	20	2			2	
H3924	060	3	1	04	01	H3924_060_3	5	3	Out of network $275.00 copayment	01	10a;		2		2			1	275.00	275.00	2	
H3924	060	3	1	04	01	H3924_060_3	5	4	Diabetic supplies and services	01	11c;		2		1	0	20	2			2	
H3924	060	3	1	04	01	H3924_060_3	5	5	Nurseline $0 Copayment	10		14c;	1	90.00	2			2			2	
H3924	060	3	1	04	01	H3924_060_3	5	6	PCP & Annual Physical Exam	11	7a;	14b;	2		2			1	10.00	10.00	2	
H3924	060	3	1	04	01	H3924_060_3	5	7	Specialist Services	01	7c;7d;7f;7i;16b;17a;18a;		2		2			1	40.00	40.00	2	
H3924	060	3	1	04	01	H3924_060_3	5	8	Outpatient Surgery and ASC	01	9a;9b;		2		2			1	350.00	350.00	2	
H3924	060	3	1	04	01	H3924_060_3	5	9	Partial Hospitalization	01	5;		2		2			1	55.00	55.00	2	
H3924	060	4	1	04	01	H3924_060_4	5	1	Out of Network $0 Copay Benefits	11	3-1;3-2;3-3;6;7g;9d;14a;14d;14e;17b;	7f;	2		2			2			2	
H3924	060	4	1	04	01	H3924_060_4	5	10	$20 copayment	01	7b;		2		2			1	20.00	20.00	2	
H3924	060	4	1	04	01	H3924_060_4	5	11	Mental health/sub abuse	01	7e;7h;9c;		2		2			1	10.00	25.00	2	
H3924	060	4	1	04	01	H3924_060_4	5	12	$30 Diagnostic Procedures, Tests and Lab	01	8a1;8a2;		2		2			1	30.00	30.00	2	
H3924	060	4	1	04	01	H3924_060_4	5	13	Diagnostic radiology	01	8b1;8b3;		2		2			1	40.00	275.00	2	
H3924	060	4	1	04	01	H3924_060_4	5	14	Therapeutic radiology	01	8b2;		2		2			1	40.00	60.00	2	
H3924	060	4	1	04	01	H3924_060_4	5	2	Medicare benefits with a 20% coinsurance	01	11a;11b;12;15;		2		1	20	20	2			2	
H3924	060	4	1	04	01	H3924_060_4	5	3	Out of network $275.00 copayment	01	10a;		2		2			1	275.00	275.00	2	
H3924	060	4	1	04	01	H3924_060_4	5	4	Diabetic supplies and services	01	11c;		2		1	0	20	2			2	
H3924	060	4	1	04	01	H3924_060_4	5	5	Nurseline $0 Copayment	10		14c;	1	90.00	2			2			2	
H3924	060	4	1	04	01	H3924_060_4	5	6	PCP & Annual Physical Exam	11	7a;	14b;	2		2			1	10.00	10.00	2	
H3924	060	4	1	04	01	H3924_060_4	5	7	Specialist Services	01	7c;7d;7f;7i;16b;17a;18a;		2		2			1	40.00	40.00	2	
H3924	060	4	1	04	01	H3924_060_4	5	8	Outpatient Surgery and ASC	01	9a;9b;		2		2			1	350.00	350.00	2	
H3924	060	4	1	04	01	H3924_060_4	5	9	Partial Hospitalization	01	5;		2		2			1	55.00	55.00	2	
H3924	060	6	1	04	01	H3924_060_6	5	1	Out of Network $0 Copay Benefits	11	3-1;3-2;3-3;6;7g;9d;14a;14d;14e;17b;	7f;	2		2			2			2	
H3924	060	6	1	04	01	H3924_060_6	5	10	$20 copayment	01	7b;		2		2			1	20.00	20.00	2	
H3924	060	6	1	04	01	H3924_060_6	5	11	Mental health/sub abuse	01	7e;7h;9c;		2		2			1	10.00	25.00	2	
H3924	060	6	1	04	01	H3924_060_6	5	12	$30 Diagnostic Procedures, Tests and Lab	01	8a1;8a2;		2		2			1	30.00	30.00	2	
H3924	060	6	1	04	01	H3924_060_6	5	13	Diagnostic radiology	01	8b1;8b3;		2		2			1	40.00	275.00	2	
H3924	060	6	1	04	01	H3924_060_6	5	14	Therapeutic radiology	01	8b2;		2		2			1	40.00	60.00	2	
H3924	060	6	1	04	01	H3924_060_6	5	2	Medicare benefits with a 20% coinsurance	01	11a;11b;12;15;		2		1	20	20	2			2	
H3924	060	6	1	04	01	H3924_060_6	5	3	Out of network $275.00 copayment	01	10a;		2		2			1	275.00	275.00	2	
H3924	060	6	1	04	01	H3924_060_6	5	4	Diabetic supplies and services	01	11c;		2		1	0	20	2			2	
H3924	060	6	1	04	01	H3924_060_6	5	5	Nurseline $0 Copayment	10		14c;	1	90.00	2			2			2	
H3924	060	6	1	04	01	H3924_060_6	5	6	PCP & Annual Physical Exam	11	7a;	14b;	2		2			1	10.00	10.00	2	
H3924	060	6	1	04	01	H3924_060_6	5	7	Specialist Services	01	7c;7d;7f;7i;16b;17a;18a;		2		2			1	40.00	40.00	2	
H3924	060	6	1	04	01	H3924_060_6	5	8	Outpatient Surgery and ASC	01	9a;9b;		2		2			1	350.00	350.00	2	
H3924	060	6	1	04	01	H3924_060_6	5	9	Partial Hospitalization	01	5;		2		2			1	55.00	55.00	2	
H3924	060	7	1	04	01	H3924_060_7	5	1	Out of Network $0 Copay Benefits	11	3-1;3-2;3-3;6;7g;9d;14a;14d;14e;17b;	7f;	2		2			2			2	
H3924	060	7	1	04	01	H3924_060_7	5	10	$20 copayment	01	7b;		2		2			1	20.00	20.00	2	
H3924	060	7	1	04	01	H3924_060_7	5	11	Mental health/sub abuse	01	7e;7h;9c;		2		2			1	10.00	25.00	2	
H3924	060	7	1	04	01	H3924_060_7	5	12	$30 Diagnostic Procedures, Tests and Lab	01	8a1;8a2;		2		2			1	30.00	30.00	2	
H3924	060	7	1	04	01	H3924_060_7	5	13	Diagnostic radiology	01	8b1;8b3;		2		2			1	40.00	275.00	2	
H3924	060	7	1	04	01	H3924_060_7	5	14	Therapeutic radiology	01	8b2;		2		2			1	40.00	60.00	2	
H3924	060	7	1	04	01	H3924_060_7	5	2	Medicare benefits with a 20% coinsurance	01	11a;11b;12;15;		2		1	20	20	2			2	
H3924	060	7	1	04	01	H3924_060_7	5	3	Out of network $275.00 copayment	01	10a;		2		2			1	275.00	275.00	2	
H3924	060	7	1	04	01	H3924_060_7	5	4	Diabetic supplies and services	01	11c;		2		1	0	20	2			2	
H3924	060	7	1	04	01	H3924_060_7	5	5	Nurseline $0 Copayment	10		14c;	1	90.00	2			2			2	
H3924	060	7	1	04	01	H3924_060_7	5	6	PCP & Annual Physical Exam	11	7a;	14b;	2		2			1	10.00	10.00	2	
H3924	060	7	1	04	01	H3924_060_7	5	7	Specialist Services	01	7c;7d;7f;7i;16b;17a;18a;		2		2			1	40.00	40.00	2	
H3924	060	7	1	04	01	H3924_060_7	5	8	Outpatient Surgery and ASC	01	9a;9b;		2		2			1	350.00	350.00	2	
H3924	060	7	1	04	01	H3924_060_7	5	9	Partial Hospitalization	01	5;		2		2			1	55.00	55.00	2	
H3924	060	8	1	04	01	H3924_060_8	5	1	Out of Network $0 Copay Benefits	11	3-1;3-2;3-3;6;7g;9d;14a;14d;14e;17b;	7f;	2		2			2			2	
H3924	060	8	1	04	01	H3924_060_8	5	10	$20 copayment	01	7b;		2		2			1	20.00	20.00	2	
H3924	060	8	1	04	01	H3924_060_8	5	11	Mental health/sub abuse	01	7e;7h;9c;		2		2			1	10.00	25.00	2	
H3924	060	8	1	04	01	H3924_060_8	5	12	$30 Diagnostic Procedures, Tests and Lab	01	8a1;8a2;		2		2			1	30.00	30.00	2	
H3924	060	8	1	04	01	H3924_060_8	5	13	Diagnostic radiology	01	8b1;8b3;		2		2			1	40.00	275.00	2	
H3924	060	8	1	04	01	H3924_060_8	5	14	Therapeutic radiology	01	8b2;		2		2			1	40.00	60.00	2	
H3924	060	8	1	04	01	H3924_060_8	5	2	Medicare benefits with a 20% coinsurance	01	11a;11b;12;15;		2		1	20	20	2			2	
H3924	060	8	1	04	01	H3924_060_8	5	3	Out of network $275.00 copayment	01	10a;		2		2			1	275.00	275.00	2	
H3924	060	8	1	04	01	H3924_060_8	5	4	Diabetic supplies and services	01	11c;		2		1	0	20	2			2	
H3924	060	8	1	04	01	H3924_060_8	5	5	Nurseline $0 Copayment	10		14c;	1	90.00	2			2			2	
H3924	060	8	1	04	01	H3924_060_8	5	6	PCP & Annual Physical Exam	11	7a;	14b;	2		2			1	10.00	10.00	2	
H3924	060	8	1	04	01	H3924_060_8	5	7	Specialist Services	01	7c;7d;7f;7i;16b;17a;18a;		2		2			1	40.00	40.00	2	
H3924	060	8	1	04	01	H3924_060_8	5	8	Outpatient Surgery and ASC	01	9a;9b;		2		2			1	350.00	350.00	2	
H3924	060	8	1	04	01	H3924_060_8	5	9	Partial Hospitalization	01	5;		2		2			1	55.00	55.00	2	
H3924	060	9	1	04	01	H3924_060_9	5	1	Out of Network $0 Copay Benefits	11	3-1;3-2;3-3;6;7g;9d;14a;14d;14e;17b;	7f;	2		2			2			2	
H3924	060	9	1	04	01	H3924_060_9	5	10	$20 copayment	01	7b;		2		2			1	20.00	20.00	2	
H3924	060	9	1	04	01	H3924_060_9	5	11	Mental health/sub abuse	01	7e;7h;9c;		2		2			1	10.00	25.00	2	
H3924	060	9	1	04	01	H3924_060_9	5	12	$30 Diagnostic Procedures, Tests and Lab	01	8a1;8a2;		2		2			1	30.00	30.00	2	
H3924	060	9	1	04	01	H3924_060_9	5	13	Diagnostic radiology	01	8b1;8b3;		2		2			1	40.00	275.00	2	
H3924	060	9	1	04	01	H3924_060_9	5	14	Therapeutic radiology	01	8b2;		2		2			1	40.00	60.00	2	
H3924	060	9	1	04	01	H3924_060_9	5	2	Medicare benefits with a 20% coinsurance	01	11a;11b;12;15;		2		1	20	20	2			2	
H3924	060	9	1	04	01	H3924_060_9	5	3	Out of network $275.00 copayment	01	10a;		2		2			1	275.00	275.00	2	
H3924	060	9	1	04	01	H3924_060_9	5	4	Diabetic supplies and services	01	11c;		2		1	0	20	2			2	
H3924	060	9	1	04	01	H3924_060_9	5	5	Nurseline $0 Copayment	10		14c;	1	90.00	2			2			2	
H3924	060	9	1	04	01	H3924_060_9	5	6	PCP & Annual Physical Exam	11	7a;	14b;	2		2			1	10.00	10.00	2	
H3924	060	9	1	04	01	H3924_060_9	5	7	Specialist Services	01	7c;7d;7f;7i;16b;17a;18a;		2		2			1	40.00	40.00	2	
H3924	060	9	1	04	01	H3924_060_9	5	8	Outpatient Surgery and ASC	01	9a;9b;		2		2			1	350.00	350.00	2	
H3924	060	9	1	04	01	H3924_060_9	5	9	Partial Hospitalization	01	5;		2		2			1	55.00	55.00	2	
H3924	803	0	1	04	01	H3924_803_0	3	1	$0	01	14a;		2		2			2			2	
H3924	803	0	1	04	01	H3924_803_0	3	2	Medicare Cost Sharing All Other Benefits	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4005	001	0	1	04	01	H4005_001_0	5	1	Group 1	11	5;6;7a;7d;7g;7h;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;10a;11c;12;15;17a;18a;	9d;16a;17a;18a;	2		1	20	20	2			2	
H4005	001	0	1	04	01	H4005_001_0	5	2	Group 2	11	3-1;3-2;3-3;7b;7c;7e;7f;7i;9c;14e;16b;	7b;7f;13a;16b;	2		1	25	25	2			2	
H4005	001	0	1	04	01	H4005_001_0	5	3	Group 3	10		14c;	1	25.00	2			2			2	
H4005	001	0	1	04	01	H4005_001_0	5	4	Group 4	01	11a;11b;		2		1	30	30	2			2	
H4005	001	0	1	04	01	H4005_001_0	5	5		11	14a;14d;17b;	10b;13b;17b;18b;	2		2			2			2	
H4005	004	0	1	04	01	H4005_004_0	6	1	Group 1	11	5;6;7a;7d;7g;7h;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;10a;11c;12;15;17a;18a;	9d;15;16a;17a;18a;	2		1	20	20	2			2	
H4005	004	0	1	04	01	H4005_004_0	6	2	Group 2	11	3-1;3-2;3-3;7b;7c;7e;7f;7i;9c;14e;16b;	7b;7f;13a;16b;	2		1	25	25	2			2	
H4005	004	0	1	04	01	H4005_004_0	6	3	Group 3	10		14c;	1	25.00	2			2			2	
H4005	004	0	1	04	01	H4005_004_0	6	4	Group 4	01	11a;11b;		2		1	30	30	2			2	
H4005	004	0	1	04	01	H4005_004_0	6	5	Group 5	11	14a;14d;17b;	10b;13b;17b;18b;	2		2			2			2	
H4005	801	0	1	04	01	H4005_801_0	5	1		01	6;14a;		2		1	0	0	2			2	
H4005	801	0	1	04	01	H4005_801_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4005	802	0	1	04	01	H4005_802_0	5	1		01	6;14a;		2		1	0	0	2			2	
H4005	802	0	1	04	01	H4005_802_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4005	804	0	1	04	01	H4005_804_0	5	1		01	6;14a;		2		1	0	0	2			2	
H4005	804	0	1	04	01	H4005_804_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4005	807	0	1	04	01	H4005_807_0	5	1		01	6;14a;		2		1	0	0	2			2	
H4005	807	0	1	04	01	H4005_807_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4005	808	0	1	04	01	H4005_808_0	5	1		01	6;14a;		2		1	0	0	2			2	
H4005	808	0	1	04	01	H4005_808_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4007	012	0	1	01	01	H4007_012_0	5	1														
H4007	013	0	1	01	01	H4007_013_0	4	1														
H4007	016	0	1	01	01	H4007_016_0	5	1														
H4007	018	0	1	01	01	H4007_018_0	5	1														
H4036	008	0	1	04	01	H4036_008_0	5	1	$0	11	9d;16b;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H4036	008	0	1	04	01	H4036_008_0	5	2	20%	11	8b2;12;	16a;18a;	2		1	20	20	2			2	
H4036	008	0	1	04	01	H4036_008_0	5	3	Ambulance	01	10a;		2		1	20	20	1	295.00	295.00	2	
H4036	008	0	1	04	01	H4036_008_0	5	4	Diag/Rad	01	8a1;8a2;8b1;8b3;		2		1	35	35	2			2	
H4036	008	0	1	04	01	H4036_008_0	5	5	PCP	01	7a;7g;		2		2			1	40.00	40.00	2	
H4036	008	0	1	04	01	H4036_008_0	5	6	SPEC	11	7b;7c;7d;7e;7f;7h;7i;	7f;14b;	2		2			1	60.00	60.00	2	
H4036	008	0	1	04	01	H4036_008_0	5	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;		2		1	40	40	2			2	
H4036	008	0	1	04	01	H4036_008_0	5	8	Eligible Supplemental Benefits	10		14c;	1	95.00	2			1	0.00	0.00	2	
H4036	008	0	1	04	01	H4036_008_0	5	9	50%	10		18b;	2		1	50	50	2			2	
H4036	009	0	1	04	01	H4036_009_0	5	1	$0	11	9d;16b;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H4036	009	0	1	04	01	H4036_009_0	5	2	20%	11	8a2;8b2;12;	16a;18a;	2		1	20	20	2			2	
H4036	009	0	1	04	01	H4036_009_0	5	3	Ambulance	01	10a;		2		1	20	20	1	295.00	295.00	2	
H4036	009	0	1	04	01	H4036_009_0	5	4	Diag/Rad	01	8a1;8b1;8b3;		2		1	35	35	2			2	
H4036	009	0	1	04	01	H4036_009_0	5	5	PCP	01	7a;7g;		2		2			1	40.00	40.00	2	
H4036	009	0	1	04	01	H4036_009_0	5	6	SPEC	11	7b;7c;7d;7e;7f;7h;7i;	7f;14b;	2		2			1	60.00	60.00	2	
H4036	009	0	1	04	01	H4036_009_0	5	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;		2		1	40	40	2			2	
H4036	009	0	1	04	01	H4036_009_0	5	8	Eligible Supplemental Benefits	10		14c;	1	95.00	2			1	0.00	0.00	2	
H4036	009	0	1	04	01	H4036_009_0	5	9	50%	10		18b;	2		1	50	50	2			2	
H4036	010	1	1	04	01	H4036_010_1	5	1	$0	11	9d;16b;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H4036	010	1	1	04	01	H4036_010_1	5	2	20%	11	8b2;12;	16a;18a;	2		1	20	20	2			2	
H4036	010	1	1	04	01	H4036_010_1	5	3	Ambulance	01	10a;		2		1	20	20	1	295.00	295.00	2	
H4036	010	1	1	04	01	H4036_010_1	5	4	Diag/Rad	01	8a1;8a2;8b1;8b3;		2		1	30	30	2			2	
H4036	010	1	1	04	01	H4036_010_1	5	5	PCP	01	7a;7g;		2		2			1	25.00	25.00	2	
H4036	010	1	1	04	01	H4036_010_1	5	6	Specialist	11	7b;7c;7d;7e;7f;7h;7i;	7f;14b;	2		2			1	60.00	60.00	2	
H4036	010	1	1	04	01	H4036_010_1	5	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;		2		1	40	40	2			2	
H4036	010	1	1	04	01	H4036_010_1	5	8	$0	10		14c;	1	95.00	2			1	0.00	0.00	2	
H4036	010	1	1	04	01	H4036_010_1	5	9	50%	10		18b;	2		1	50	50	2			2	
H4036	010	2	1	04	01	H4036_010_2	5	1	$0	11	9d;16b;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H4036	010	2	1	04	01	H4036_010_2	5	2	20%	11	8b2;12;	16a;18a;	2		1	20	20	2			2	
H4036	010	2	1	04	01	H4036_010_2	5	3	Ambulance	01	10a;		2		1	20	20	1	295.00	295.00	2	
H4036	010	2	1	04	01	H4036_010_2	5	4	Diag/Rad	01	8a1;8a2;8b1;8b3;		2		1	30	30	2			2	
H4036	010	2	1	04	01	H4036_010_2	5	5	PCP	01	7a;7g;		2		2			1	35.00	35.00	2	
H4036	010	2	1	04	01	H4036_010_2	5	6	Specialist	11	7b;7c;7d;7e;7f;7h;7i;	7f;14b;	2		2			1	60.00	60.00	2	
H4036	010	2	1	04	01	H4036_010_2	5	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;		2		1	40	40	2			2	
H4036	010	2	1	04	01	H4036_010_2	5	8	$0	10		14c;	1	95.00	2			1	0.00	0.00	2	
H4036	010	2	1	04	01	H4036_010_2	5	9	50%	10		18b;	2		1	50	50	2			2	
H4036	012	1	1	04	01	H4036_012_1	5	1	$0	11	9d;16b;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H4036	012	1	1	04	01	H4036_012_1	5	2	20%	11	8b2;12;	16a;18a;	2		1	20	20	2			2	
H4036	012	1	1	04	01	H4036_012_1	5	3	Ambulance	01	10a;		2		1	20	20	1	295.00	295.00	2	
H4036	012	1	1	04	01	H4036_012_1	5	4	Diag/Rad	01	8a1;8a2;8b1;8b3;		2		1	30	30	2			2	
H4036	012	1	1	04	01	H4036_012_1	5	5	PCP	01	7a;7g;		2		2			1	25.00	25.00	2	
H4036	012	1	1	04	01	H4036_012_1	5	6	Specialist	11	7b;7c;7d;7e;7f;7h;7i;	7f;14b;	2		2			1	50.00	50.00	2	
H4036	012	1	1	04	01	H4036_012_1	5	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;		2		1	40	40	2			2	
H4036	012	1	1	04	01	H4036_012_1	5	8	$0	10		14c;	1	95.00	2			1	0.00	0.00	2	
H4036	012	1	1	04	01	H4036_012_1	5	9	50%	10		18b;	2		1	50	50	2			2	
H4036	012	2	1	04	01	H4036_012_2	5	1	$0	11	9d;16b;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H4036	012	2	1	04	01	H4036_012_2	5	2	20%	11	8b2;12;	16a;18a;	2		1	20	20	2			2	
H4036	012	2	1	04	01	H4036_012_2	5	3	Ambulance	01	10a;		2		1	20	20	1	295.00	295.00	2	
H4036	012	2	1	04	01	H4036_012_2	5	4	Diag/Rad	01	8a1;8a2;8b1;8b3;		2		1	30	30	2			2	
H4036	012	2	1	04	01	H4036_012_2	5	5	PCP	01	7a;7g;		2		2			1	25.00	25.00	2	
H4036	012	2	1	04	01	H4036_012_2	5	6	Specialist	11	7b;7c;7d;7e;7f;7h;7i;	7f;14b;	2		2			1	50.00	50.00	2	
H4036	012	2	1	04	01	H4036_012_2	5	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;		2		1	40	40	2			2	
H4036	012	2	1	04	01	H4036_012_2	5	8	$0	10		14c;	1	95.00	2			1	0.00	0.00	2	
H4036	012	2	1	04	01	H4036_012_2	5	9	50%	10		18b;	2		1	50	50	2			2	
H4036	016	0	1	04	01	H4036_016_0	4	1	$0	11	9d;16b;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H4036	016	0	1	04	01	H4036_016_0	4	2	20%	11	8b2;12;	16a;18a;	2		1	20	20	2			2	
H4036	016	0	1	04	01	H4036_016_0	4	3	Ambulance	01	10a;		2		1	20	20	1	295.00	295.00	2	
H4036	016	0	1	04	01	H4036_016_0	4	4	Diag/Rad	01	8a1;8a2;8b1;8b3;		2		1	35	35	2			2	
H4036	016	0	1	04	01	H4036_016_0	4	5	PCP	01	7a;7g;		2		2			1	40.00	40.00	2	
H4036	016	0	1	04	01	H4036_016_0	4	6	SPEC	11	7b;7c;7d;7e;7f;7h;7i;	7f;14b;	2		2			1	60.00	60.00	2	
H4036	016	0	1	04	01	H4036_016_0	4	7	General	01	3-1;3-2;3-3;5;6;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;		2		1	40	40	2			2	
H4036	016	0	1	04	01	H4036_016_0	4	8	Eligible Supplemental Benefits	10		14c;	1	95.00	2			1	0.00	0.00	2	
H4036	016	0	1	04	01	H4036_016_0	4	9	50%	11	9a;9b;	18b;	2		1	50	50	2			2	
H4036	801	0	1	04	01	H4036_801_0	1	1		01	6;14a;		2		1	0	0	2			2	
H4036	801	0	1	04	01	H4036_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4036	802	0	1	04	01	H4036_802_0	1	1		01	6;14a;		2		1	0	0	2			2	
H4036	802	0	1	04	01	H4036_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4036	803	0	1	04	01	H4036_803_0	1	1		01	6;14a;		2		1	0	0	2			2	
H4036	803	0	1	04	01	H4036_803_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4036	805	0	1	04	01	H4036_805_0	1	1		01	6;14a;		2		1	0	0	2			2	
H4036	805	0	1	04	01	H4036_805_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4036	806	0	2	04	01	H4036_806_0	1	1		01	6;14a;		2		1	0	0	2			2	
H4036	806	0	2	04	01	H4036_806_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4069	001	0	1	04	01	H4069_001_0	8	1	40% OON Coinsurance Group	11	3-1;3-2;3-3;5;6;9c;9d;14a;14d;14e;15;16b;17a;18a;	9d;14b;	2		1	40	40	2			2	
H4069	001	0	1	04	01	H4069_001_0	8	10	35% Coinsurance Group	01	11a;11b;11c;		2		1	35	35	2			2	
H4069	001	0	1	04	01	H4069_001_0	8	11	$0 - 50% OON Group	01	8a1;		2		1	50	50	1	0.00	0.00	2	
H4069	001	0	1	04	01	H4069_001_0	8	2	$35 OON Copayment Group	01	7a;7g;		2		2			1	35.00	35.00	2	
H4069	001	0	1	04	01	H4069_001_0	8	3	$50 Copayment Group	01	7b;7c;7d;7e;7f;7h;7i;		2		2			1	50.00	50.00	2	
H4069	001	0	1	04	01	H4069_001_0	8	4	20% Coinsurance Air $325 Copayment Group	01	10a;		2		1	20	20	1	325.00	325.00	2	
H4069	001	0	1	04	01	H4069_001_0	8	5	20% OON Coinsurance Group	11	12;	16a;	2		1	20	20	2			2	
H4069	001	0	1	04	01	H4069_001_0	8	6	$0 Copayment	01	17b;		2		2			1	0.00	0.00	2	
H4069	001	0	1	04	01	H4069_001_0	8	7	50% OON Group	01	8a2;8b1;8b2;8b3;9a;9b;		2		1	50	50	2			2	
H4069	001	0	1	04	01	H4069_001_0	8	8	$0 Copay Group with $69 Max Benefit	10		17a;	2		2			1	0.00	0.00	2	
H4069	001	0	1	04	01	H4069_001_0	8	9	$0 Copayment Group	10		14c;	1	95.00	2			1	0.00	0.00	2	
H4069	801	0	1	04	01	H4069_801_0	1	1		01	6;14a;		2		1	0	0	2			2	
H4069	801	0	1	04	01	H4069_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4069	802	0	1	04	01	H4069_802_0	1	1		01	6;14a;		2		1	0	0	2			2	
H4069	802	0	1	04	01	H4069_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4069	803	0	1	04	01	H4069_803_0	1	1		01	6;14a;		2		1	0	0	2			2	
H4069	803	0	1	04	01	H4069_803_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4069	804	0	2	04	01	H4069_804_0	3	1		01	6;14a;		2		1	0	0	2			2	
H4069	804	0	2	04	01	H4069_804_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4091	001	0	1	04	01	H4091_001_0	11	1	Coinsurance Group	01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4091	001	0	1	04	01	H4091_001_0	11	2	Non-Medicare covered	10		9d;17a;17b;	2		2			2			2	
H4091	001	0	1	04	01	H4091_001_0	11	3	Hearing and Podiatry	10		7f;18a;18b;	2		2			2			2	
H4091	001	0	1	04	01	H4091_001_0	11	4	Zero Coinsurance	01	6;14a;		2		2			2			2	
H4091	002	0	1	04	01	H4091_002_0	11	1	Coinsurance Group	01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4091	002	0	1	04	01	H4091_002_0	11	2	non-medicare covered services	10		9d;17a;17b;	2		2			2			2	
H4091	002	0	1	04	01	H4091_002_0	11	3	Zeo Coinsurance	01	6;14a;		2		2			2			2	
H4141	003	0	1	01	01	H4141_003_0	3	1														
H4141	004	0	1	01	01	H4141_004_0	2	1														
H4141	015	0	1	01	01	H4141_015_0	3	1														
H4141	017	3	1	01	01	H4141_017_3	2	1														
H4141	017	4	1	01	01	H4141_017_4	3	1														
H4213	016	1	1	09	04	H4213_016_1	7	1	Ambulance Services	01	10a;				2			1	350.00	350.00	2	
H4213	016	1	1	09	04	H4213_016_1	7	10	Mental Health / Psych /  PT / SP / OT	01	7c;7e;7h;7i;9c;				1	40	40	1	40.00	40.00	2	
H4213	016	1	1	09	04	H4213_016_1	7	11	Partial Hospitalization	01	5;				1	40	40	1	55.00	55.00	2	
H4213	016	1	1	09	04	H4213_016_1	7	12	Other Health Care Professional	01	7g;				1	40	40	1	20.00	315.00	2	
H4213	016	1	1	09	04	H4213_016_1	7	13	Outpatient Hospital / ASC Services	01	9a;9b;				1	40	40	1	315.00	315.00	2	
H4213	016	1	1	09	04	H4213_016_1	7	14	Pulmonary Services	01	3-3;				1	40	40	1	30.00	30.00	2	
H4213	016	1	1	09	04	H4213_016_1	7	15	Cardiac Services	01	3-1;3-2;				1	40	40	1	45.00	45.00	2	
H4213	016	1	1	09	04	H4213_016_1	7	2	Fitness Benefit/Blood Services	11	9d;	9d;14c;	2		2			2			2	
H4213	016	1	1	09	04	H4213_016_1	7	3	Preventive / Home Health / Lab Services	11	6;8a2;14a;14d;14e;	14b;	2		1	0	40	2			2	
H4213	016	1	1	09	04	H4213_016_1	7	4	Primary Care Physician	01	7a;				1	40	40	1	20.00	20.00	2	
H4213	016	1	1	09	04	H4213_016_1	7	5	Chiropractic Services	01	7b;				1	40	40	1	20.00	20.00	2	
H4213	016	1	1	09	04	H4213_016_1	7	6	Other Services	01	8a1;8b2;8b3;11a;11b;11c;12;15;				1	20	40	2			2	
H4213	016	1	1	09	04	H4213_016_1	7	7	Diagnostic Radiological Services	01	8b1;				1	40	40	1	315.00	315.00	2	
H4213	016	1	1	09	04	H4213_016_1	7	8	Podiatry	01	7f;				1	40	40	1	50.00	315.00	2	
H4213	016	1	1	09	04	H4213_016_1	7	9	$50 MIN/$50 MAX	01	7d;16b;17a;17b;18a;				1	40	40	1	50.00	50.00	2	
H4213	016	3	1	09	04	H4213_016_3	5	1	Ambulance Services	01	10a;				2			1	350.00	350.00	2	
H4213	016	3	1	09	04	H4213_016_3	5	10	Mental Health / Psych /  PT / SP / OT	01	7c;7e;7h;7i;9c;				1	40	40	1	40.00	40.00	2	
H4213	016	3	1	09	04	H4213_016_3	5	11	Partial Hospitalization	01	5;				1	40	40	1	55.00	55.00	2	
H4213	016	3	1	09	04	H4213_016_3	5	12	Other Health Care Professional	01	7g;				1	40	40	1	30.00	315.00	2	
H4213	016	3	1	09	04	H4213_016_3	5	13	Outpatient Hospital / ASC Services	01	9a;9b;				1	40	40	1	315.00	315.00	2	
H4213	016	3	1	09	04	H4213_016_3	5	14	Pulmonary Services	01	3-3;				1	40	40	1	30.00	30.00	2	
H4213	016	3	1	09	04	H4213_016_3	5	15	Cardiac Services	01	3-1;3-2;				1	40	40	1	45.00	45.00	2	
H4213	016	3	1	09	04	H4213_016_3	5	2	Fitness Benefit/Blood Services	11	9d;	9d;14c;	2		2			2			2	
H4213	016	3	1	09	04	H4213_016_3	5	3	Preventive / Home Health / Lab Services	11	6;8a2;14a;14d;14e;	14b;	2		1	0	40	2			2	
H4213	016	3	1	09	04	H4213_016_3	5	4	Primary Care Physician	01	7a;				1	40	40	1	30.00	30.00	2	
H4213	016	3	1	09	04	H4213_016_3	5	5	Chiropractic Services	01	7b;				1	40	40	1	20.00	20.00	2	
H4213	016	3	1	09	04	H4213_016_3	5	6	Other Services	01	8a1;8b2;8b3;11a;11b;11c;12;15;				1	20	40	2			2	
H4213	016	3	1	09	04	H4213_016_3	5	7	Diagnostic Radiological Services	01	8b1;				1	40	40	1	330.00	330.00	2	
H4213	016	3	1	09	04	H4213_016_3	5	8	Podiatry	01	7f;				1	40	40	1	50.00	315.00	2	
H4213	016	3	1	09	04	H4213_016_3	5	9	$50 MIN/$50 MAX	01	7d;16b;17a;17b;18a;				1	40	40	1	50.00	50.00	2	
H4213	016	4	1	09	04	H4213_016_4	5	1	Ambulance Services	01	10a;				2			1	350.00	350.00	2	
H4213	016	4	1	09	04	H4213_016_4	5	10	Mental Health / Psych /  PT / SP / OT	01	7c;7e;7h;7i;9c;				1	40	40	1	40.00	40.00	2	
H4213	016	4	1	09	04	H4213_016_4	5	11	Partial Hospitalization	01	5;				1	40	40	1	55.00	55.00	2	
H4213	016	4	1	09	04	H4213_016_4	5	12	Other Health Care Professional	01	7g;				1	40	40	1	30.00	315.00	2	
H4213	016	4	1	09	04	H4213_016_4	5	13	Outpatient Hospital / ASC Services	01	9a;9b;				1	40	40	1	315.00	315.00	2	
H4213	016	4	1	09	04	H4213_016_4	5	14	Pulmonary Services	01	3-3;				1	40	40	1	30.00	30.00	2	
H4213	016	4	1	09	04	H4213_016_4	5	15	Cardiac Services	01	3-1;3-2;				1	40	40	1	45.00	45.00	2	
H4213	016	4	1	09	04	H4213_016_4	5	2	Fitness Benefit/Blood Services	11	9d;	9d;14c;	2		2			2			2	
H4213	016	4	1	09	04	H4213_016_4	5	3	Preventive / Home Health / Lab Services	11	6;8a2;14a;14d;14e;	14b;	2		1	0	40	2			2	
H4213	016	4	1	09	04	H4213_016_4	5	4	Primary Care Physician	01	7a;				1	40	40	1	30.00	30.00	2	
H4213	016	4	1	09	04	H4213_016_4	5	5	Chiropractic Services	01	7b;				1	40	40	1	20.00	20.00	2	
H4213	016	4	1	09	04	H4213_016_4	5	6	Other Services	01	8a1;8b2;8b3;11a;11b;11c;12;15;				1	20	40	2			2	
H4213	016	4	1	09	04	H4213_016_4	5	7	Diagnostic Radiological Services	01	8b1;				1	40	40	1	330.00	330.00	2	
H4213	016	4	1	09	04	H4213_016_4	5	8	Podiatry	01	7f;				1	40	40	1	50.00	315.00	2	
H4213	016	4	1	09	04	H4213_016_4	5	9	$50 MIN/$50 MAX	01	7d;16b;17a;17b;18a;				1	40	40	1	50.00	50.00	2	
H4213	017	1	1	09	04	H4213_017_1	7	1	Ambulance Services	01	10a;				2			1	350.00	350.00	2	
H4213	017	1	1	09	04	H4213_017_1	7	10	Mental Health / Psych /  PT / SP / OT	01	7c;7e;7h;7i;9c;				1	40	40	1	40.00	40.00	2	
H4213	017	1	1	09	04	H4213_017_1	7	11	Partial Hospitalization	01	5;				1	40	40	1	55.00	55.00	2	
H4213	017	1	1	09	04	H4213_017_1	7	12	Other Health Care Professional	01	7g;				1	40	40	1	20.00	315.00	2	
H4213	017	1	1	09	04	H4213_017_1	7	13	Outpatient Hospital / ASC Services	01	9a;9b;				1	40	40	1	315.00	315.00	2	
H4213	017	1	1	09	04	H4213_017_1	7	14	Pulmonary Services	01	3-3;				1	40	40	1	30.00	30.00	2	
H4213	017	1	1	09	04	H4213_017_1	7	15	Cardiac Services	01	3-1;3-2;				1	40	40	1	45.00	45.00	2	
H4213	017	1	1	09	04	H4213_017_1	7	2	Fitness Benefit/Blood Services	11	9d;	9d;14c;	2		2			2			2	
H4213	017	1	1	09	04	H4213_017_1	7	3	Preventive / Home Health / Lab Services	11	6;8a2;14a;14d;14e;	14b;	2		1	0	40	2			2	
H4213	017	1	1	09	04	H4213_017_1	7	4	Primary Care Physician	01	7a;				1	40	40	1	20.00	20.00	2	
H4213	017	1	1	09	04	H4213_017_1	7	5	Chiropractic Services	01	7b;				1	40	40	1	20.00	20.00	2	
H4213	017	1	1	09	04	H4213_017_1	7	6	Other Services	01	8a1;8b2;8b3;11a;11b;11c;12;15;				1	20	40	2			2	
H4213	017	1	1	09	04	H4213_017_1	7	7	Diagnostic Radiological Services	01	8b1;				1	40	40	1	315.00	315.00	2	
H4213	017	1	1	09	04	H4213_017_1	7	8	Podiatry	01	7f;				1	40	40	1	50.00	315.00	2	
H4213	017	1	1	09	04	H4213_017_1	7	9	$50 MIN/$50 MAX	01	7d;16b;17a;17b;18a;				1	40	40	1	50.00	50.00	2	
H4213	017	5	1	09	04	H4213_017_5	7	1	Ambulance Services	01	10a;				2			1	350.00	350.00	2	
H4213	017	5	1	09	04	H4213_017_5	7	10	Mental Health / Psych /  PT / SP / OT	01	7c;7e;7h;7i;9c;				1	40	40	1	40.00	40.00	2	
H4213	017	5	1	09	04	H4213_017_5	7	11	Partial Hospitalization	01	5;				1	40	40	1	55.00	55.00	2	
H4213	017	5	1	09	04	H4213_017_5	7	12	Other Health Care Professional	01	7g;				1	40	40	1	30.00	315.00	2	
H4213	017	5	1	09	04	H4213_017_5	7	13	Outpatient Hospital / ASC Services	01	9a;9b;				1	40	40	1	315.00	315.00	2	
H4213	017	5	1	09	04	H4213_017_5	7	14	Pulmonary Services	01	3-3;				1	40	40	1	30.00	30.00	2	
H4213	017	5	1	09	04	H4213_017_5	7	15	Cardiac Services	01	3-1;3-2;				1	40	40	1	45.00	45.00	2	
H4213	017	5	1	09	04	H4213_017_5	7	2	Fitness Benefit/Blood Services	11	9d;	9d;14c;	2		2			2			2	
H4213	017	5	1	09	04	H4213_017_5	7	3	Preventive / Home Health / Lab Services	11	6;8a2;14a;14d;14e;	14b;	2		1	0	40	2			2	
H4213	017	5	1	09	04	H4213_017_5	7	4	Primary Care Physician	01	7a;				1	40	40	1	30.00	30.00	2	
H4213	017	5	1	09	04	H4213_017_5	7	5	Chiropractic Services	01	7b;				1	40	40	1	20.00	20.00	2	
H4213	017	5	1	09	04	H4213_017_5	7	6	Other Services	01	8a1;8b2;8b3;11a;11b;11c;12;15;				1	20	40	2			2	
H4213	017	5	1	09	04	H4213_017_5	7	7	Diagnostic Radiological Services	01	8b1;				1	40	40	1	330.00	330.00	2	
H4213	017	5	1	09	04	H4213_017_5	7	8	Podiatry	01	7f;				1	40	40	1	50.00	315.00	2	
H4213	017	5	1	09	04	H4213_017_5	7	9	$50 MIN/$50 MAX	01	7d;16b;17a;17b;18a;				1	40	40	1	50.00	50.00	2	
H4213	017	6	1	09	04	H4213_017_6	7	1	Ambulance Services	01	10a;				2			1	350.00	350.00	2	
H4213	017	6	1	09	04	H4213_017_6	7	10	Mental Health / Psych /  PT / SP / OT	01	7c;7e;7h;7i;9c;				1	40	40	1	40.00	40.00	2	
H4213	017	6	1	09	04	H4213_017_6	7	11	Partial Hospitalization	01	5;				1	40	40	1	55.00	55.00	2	
H4213	017	6	1	09	04	H4213_017_6	7	12	Other Health Care Professional	01	7g;				1	40	40	1	30.00	315.00	2	
H4213	017	6	1	09	04	H4213_017_6	7	13	Outpatient Hospital / ASC Services	01	9a;9b;				1	40	40	1	315.00	315.00	2	
H4213	017	6	1	09	04	H4213_017_6	7	14	Pulmonary Services	01	3-3;				1	40	40	1	30.00	30.00	2	
H4213	017	6	1	09	04	H4213_017_6	7	15	Cardiac Services	01	3-1;3-2;				1	40	40	1	45.00	45.00	2	
H4213	017	6	1	09	04	H4213_017_6	7	2	Fitness Benefit/Blood Services	11	9d;	9d;14c;	2		2			2			2	
H4213	017	6	1	09	04	H4213_017_6	7	3	Preventive / Home Health / Lab Services	11	6;8a2;14a;14d;14e;	14b;	2		1	0	40	2			2	
H4213	017	6	1	09	04	H4213_017_6	7	4	Primary Care Physician	01	7a;				1	40	40	1	30.00	30.00	2	
H4213	017	6	1	09	04	H4213_017_6	7	5	Chiropractic Services	01	7b;				1	40	40	1	20.00	20.00	2	
H4213	017	6	1	09	04	H4213_017_6	7	6	Other Services	01	8a1;8b2;8b3;11a;11b;11c;12;15;				1	20	40	2			2	
H4213	017	6	1	09	04	H4213_017_6	7	7	Diagnostic Radiological Services	01	8b1;				1	40	40	1	330.00	330.00	2	
H4213	017	6	1	09	04	H4213_017_6	7	8	Podiatry	01	7f;				1	40	40	1	50.00	315.00	2	
H4213	017	6	1	09	04	H4213_017_6	7	9	$50 MIN/$50 MAX	01	7d;16b;17a;17b;18a;				1	40	40	1	50.00	50.00	2	
H4262	001	1	1	09	04	H4262_001_1	4	1	Part B Drugs	01	15;				1	0	20	2			2	
H4262	001	1	1	09	04	H4262_001_1	4	2	Zero Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;16b;17a;17b;18a;	9d;14b;14c;	2		2			2			2	
H4262	001	2	1	09	04	H4262_001_2	4	1	Part B Drugs	01	15;				1	0	20	2			2	
H4262	001	2	1	09	04	H4262_001_2	4	2	Zero Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;16b;17a;17b;18a;	9d;14b;14c;	2		2			2			2	
H4262	001	3	1	09	04	H4262_001_3	4	1	Part B Drugs	01	15;				1	0	20	2			2	
H4262	001	3	1	09	04	H4262_001_3	4	2	Zero Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;16b;17a;17b;18a;	9d;14b;14c;	2		2			2			2	
H4262	001	4	1	09	04	H4262_001_4	4	1	Part B Drugs	01	15;				1	0	20	2			2	
H4262	001	4	1	09	04	H4262_001_4	4	2	Zero Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;16b;17a;17b;18a;	9d;14b;14c;	2		2			2			2	
H4262	001	6	1	09	04	H4262_001_6	4	1	Part B Drugs	01	15;				1	0	20	2			2	
H4262	001	6	1	09	04	H4262_001_6	4	2	Zero Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;16b;17a;17b;18a;	9d;14b;14c;	2		2			2			2	
H4262	801	0	1	09	04	H4262_801_0	4	1		01	6;14a;		2		1	0	0	2			2	
H4262	801	0	1	09	04	H4262_801_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4461	004	0	1	01	01	H4461_004_0	3	1														
H4461	022	0	1	01	01	H4461_022_0	3	1														
H4461	025	0	1	01	01	H4461_025_0	3	1														
H4461	029	0	1	01	01	H4461_029_0	3	1														
H4461	030	1	1	01	01	H4461_030_1	2	1														
H4461	030	2	1	01	01	H4461_030_2	2	1														
H4461	030	3	1	01	01	H4461_030_3	3	1														
H4461	031	1	1	01	01	H4461_031_1	4	1														
H4461	031	2	1	01	01	H4461_031_2	2	1														
H4461	031	3	1	01	01	H4461_031_3	3	1														
H4461	034	0	1	01	01	H4461_034_0	2	1														
H4497	001	1	1	04	01	H4497_001_1	10	1	OON Benefits	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14a;14d;14e;16b;17a;17b;18a;	9d;	2		1	30	30	2			2	
H4497	001	1	1	04	01	H4497_001_1	10	2	Ambulance/Dental Supplemental Coverage	11	10a;	16a;	2		1	50	50	2			2	
H4497	001	1	1	04	01	H4497_001_1	10	3	OTC Benefit	10		13b;	1	20.00	2			2			2	
H4497	001	1	1	04	01	H4497_001_1	10	4	Meal Benefit	10		13c;	2		2			2			2	
H4497	001	1	1	04	01	H4497_001_1	10	5	Other Supplemental Coverage	10		14c;	1	352.00	2			2			2	
H4497	001	1	1	04	01	H4497_001_1	10	6	Diabetic Supplies and Services	01	11c;		2		1	20	20	2			2	
H4497	001	1	1	04	01	H4497_001_1	10	7	Medicare Part B Rx Drugs	01	15;		2		1	20	20	2			2	
H4497	001	1	1	04	01	H4497_001_1	10	8	Routine Eye Exams	10		17a;	2		2			1	50.00	50.00	2	
H4497	001	1	1	04	01	H4497_001_1	10	9	Routine Eyewear	10		17b;	2		2			2			2	
H4497	001	2	1	04	01	H4497_001_2	9	1	OON Benefits	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14a;14d;14e;16b;17a;17b;18a;	9d;	2		1	30	30	2			2	
H4497	001	2	1	04	01	H4497_001_2	9	2	Ambulance/Dental Supplemental Coverage	11	10a;	16a;	2		1	50	50	2			2	
H4497	001	2	1	04	01	H4497_001_2	9	3	OTC Benefit	10		13b;	1	20.00	2			2			2	
H4497	001	2	1	04	01	H4497_001_2	9	4	Meal Benefit	10		13c;	2		2			2			2	
H4497	001	2	1	04	01	H4497_001_2	9	5	Other Supplemental Coverage	10		14c;	1	352.00	2			2			2	
H4497	001	2	1	04	01	H4497_001_2	9	6	Diabetic Supplies and Services	01	11c;		2		1	20	20	2			2	
H4497	001	2	1	04	01	H4497_001_2	9	7	Medicare Part B Rx Drugs	01	15;		2		1	20	20	2			2	
H4497	001	2	1	04	01	H4497_001_2	9	8	Routine Eye Exams	10		17a;	2		2			1	50.00	50.00	2	
H4497	001	2	1	04	01	H4497_001_2	9	9	Routine Eyewear	10		17b;	2		2			2			2	
H4497	002	1	1	04	01	H4497_002_1	9	1	OON Benefits	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14a;14d;14e;16b;17a;17b;18a;	9d;	2		1	30	30	2			2	
H4497	002	1	1	04	01	H4497_002_1	9	2	Ambulance/Dental Supplemental Coverage	11	10a;	16a;	2		1	50	50	2			2	
H4497	002	1	1	04	01	H4497_002_1	9	3	OTC Benefit	10		13b;	1	20.00	2			2			2	
H4497	002	1	1	04	01	H4497_002_1	9	4	Meal Benefit	10		13c;	2		2			2			2	
H4497	002	1	1	04	01	H4497_002_1	9	5	Other Supplemental Coverage	10		14c;	1	352.00	2			2			2	
H4497	002	1	1	04	01	H4497_002_1	9	6	Diabetic Supplies and Services	01	11c;		2		1	20	20	2			2	
H4497	002	1	1	04	01	H4497_002_1	9	7	Medicare Part B Rx Drugs	01	15;		2		1	20	20	2			2	
H4497	002	1	1	04	01	H4497_002_1	9	8	Routine Eye Exams	10		17a;	2		2			1	50.00	50.00	2	
H4497	002	1	1	04	01	H4497_002_1	9	9	Routine Eyewear	10		17b;	2		2			2			2	
H4497	002	2	1	04	01	H4497_002_2	9	1	OON Benefits	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14a;14d;14e;16b;17a;17b;18a;	9d;	2		1	30	30	2			2	
H4497	002	2	1	04	01	H4497_002_2	9	2	Ambulance/Dental Supplemental Coverage	11	10a;	16a;	2		1	50	50	2			2	
H4497	002	2	1	04	01	H4497_002_2	9	3	OTC Benefit	10		13b;	1	20.00	2			2			2	
H4497	002	2	1	04	01	H4497_002_2	9	4	Meal Benefit	10		13c;	2		2			2			2	
H4497	002	2	1	04	01	H4497_002_2	9	5	Other Supplemental Coverage	10		14c;	1	352.00	2			2			2	
H4497	002	2	1	04	01	H4497_002_2	9	6	Diabetic Supplies and Services	01	11c;		2		1	20	20	2			2	
H4497	002	2	1	04	01	H4497_002_2	9	7	Medicare Part B Rx Drugs	01	15;		2		1	20	20	2			2	
H4497	002	2	1	04	01	H4497_002_2	9	8	Routine Eye Exams	10		17a;	2		2			1	50.00	50.00	2	
H4497	002	2	1	04	01	H4497_002_2	9	9	Routine Eyewear	10		17b;	2		2			2			2	
H4497	003	1	1	04	01	H4497_003_1	9	1	OON Benefits	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14a;14d;14e;16b;17a;17b;18a;	9d;	2		1	30	30	2			2	
H4497	003	1	1	04	01	H4497_003_1	9	10	Eyewear	10		17b;	2		2			2			2	
H4497	003	1	1	04	01	H4497_003_1	9	2	Ambulance/Preventive Dental	11	10a;	16a;	2		1	50	50	2			2	
H4497	003	1	1	04	01	H4497_003_1	9	3	OTC Benefit	10		13b;	1	20.00	2			2			2	
H4497	003	1	1	04	01	H4497_003_1	9	4	Meal Benefit	10		13c;	2		2			2			2	
H4497	003	1	1	04	01	H4497_003_1	9	5	Other Supplemental Coverage	10		14c;	1	352.00	2			2			2	
H4497	003	1	1	04	01	H4497_003_1	9	6	Diabetic Supplies and Services	01	11c;		2		1	20	20	2			2	
H4497	003	1	1	04	01	H4497_003_1	9	7	Medicare Part B Rx Drugs	01	15;		2		1	20	20	2			2	
H4497	003	1	1	04	01	H4497_003_1	9	8	Comprehensive Dental	10		16b;	2		1	55	70	2			2	
H4497	003	1	1	04	01	H4497_003_1	9	9	Routine Eye Exams	10		17a;	2		2			1	50.00	50.00	2	
H4497	003	2	1	04	01	H4497_003_2	9	1	OON Benefits	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14a;14d;14e;16b;17a;17b;18a;	9d;	2		1	30	30	2			2	
H4497	003	2	1	04	01	H4497_003_2	9	10	Eyewear	10		17b;	2		2			2			2	
H4497	003	2	1	04	01	H4497_003_2	9	2	Ambulance/Preventive Dental	11	10a;	16a;	2		1	50	50	2			2	
H4497	003	2	1	04	01	H4497_003_2	9	3	OTC Benefit	10		13b;	1	20.00	2			2			2	
H4497	003	2	1	04	01	H4497_003_2	9	4	Meal Benefit	10		13c;	2		2			2			2	
H4497	003	2	1	04	01	H4497_003_2	9	5	Other Supplemental Coverage	10		14c;	1	352.00	2			2			2	
H4497	003	2	1	04	01	H4497_003_2	9	6	Diabetic Supplies and Services	01	11c;		2		1	20	20	2			2	
H4497	003	2	1	04	01	H4497_003_2	9	7	Medicare Part B Rx Drugs	01	15;		2		1	20	20	2			2	
H4497	003	2	1	04	01	H4497_003_2	9	8	Comprehensive Dental	10		16b;	2		1	55	70	2			2	
H4497	003	2	1	04	01	H4497_003_2	9	9	Routine Eye Exams	10		17a;	2		2			1	50.00	50.00	2	
H4497	801	0	1	04	01	H4497_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
H4497	801	0	1	04	01	H4497_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4497	802	0	1	04	01	H4497_802_0	2	1		01	6;14a;		2		1	0	0	2			2	
H4497	802	0	1	04	01	H4497_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4497	803	0	1	04	01	H4497_803_0	2	1		01	6;14a;		2		1	0	0	2			2	
H4497	803	0	1	04	01	H4497_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4605	001	0	1	04	01	H4605_001_0	8	1	Routine Eye Exam and Eyewear	10		17a;17b;	2		2			1	0.00	0.00	2	
H4605	001	0	1	04	01	H4605_001_0	8	2	Eligible Supplemental Benefits	10		14c;	2		2			1	0.00	0.00	2	
H4605	001	0	1	04	01	H4605_001_0	8	3	Ambulance Services	01	10a;		2		2			1	275.00	275.00	2	
H4605	001	0	1	04	01	H4605_001_0	8	4	All Other OON 50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;16a;	2		1	50	50	2			2	
H4605	002	0	1	04	01	H4605_002_0	9	1	Routine Eye Exam and Eyewear	10		17a;17b;	2		2			1	0.00	0.00	2	
H4605	002	0	1	04	01	H4605_002_0	9	2	Eligible Supplemental Benefits	10		14c;	2		2			1	0.00	0.00	2	
H4605	002	0	1	04	01	H4605_002_0	9	3	Ambulance Services	01	10a;		2		2			1	275.00	275.00	2	
H4605	002	0	1	04	01	H4605_002_0	9	4	All Other OON 50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;16a;	2		1	50	50	2			2	
H4605	004	0	1	04	01	H4605_004_0	8	1	Routine Eye Exam and Eyewear	10		17a;17b;	2		2			1	0.00	0.00	2	
H4605	004	0	1	04	01	H4605_004_0	8	2	Eligible Supplemental Benefits	10		14c;	2		2			1	0.00	0.00	2	
H4605	004	0	1	04	01	H4605_004_0	8	3	Ambulance Services	01	10a;		2		2			1	250.00	250.00	2	
H4605	004	0	1	04	01	H4605_004_0	8	4	All Other OON 50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;16a;16b;	2		1	50	50	2			2	
H4605	004	0	1	04	01	H4605_004_0	8	5	Hearing Exams	10		18a;	2		2			1	150.00	150.00	2	
H4605	004	0	1	04	01	H4605_004_0	8	6	Hearing Aids	10		18b;	2		2			1	599.00	899.00	2	
H4605	801	0	1	04	01	H4605_801_0	3	1		01	6;14a;		2		1	0	0	2			2	
H4605	801	0	1	04	01	H4605_801_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4605	802	0	1	04	01	H4605_802_0	3	1		01	6;14a;		2		1	0	0	2			2	
H4605	802	0	1	04	01	H4605_802_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4754	004	0	1	04	01	H4754_004_0	8	1	50% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;18a;	14b;17a;	2		1	50	50	2			2	
H4754	004	0	1	04	01	H4754_004_0	8	2	Ambulance	01	10a;		2		2			1	200.00	200.00	2	
H4754	004	0	1	04	01	H4754_004_0	8	3	Mandatory / Enhanced Benefits	10		14c;	2		2			2			2	
H4754	004	0	1	04	01	H4754_004_0	8	4	Zero Dollar Copay	01	17b;		2		2			2			2	
H4754	004	0	1	04	01	H4754_004_0	8	5	Hearing Aids	10		18a;18b;	2		2			1	699.00	999.00	2	
H4754	004	0	1	04	01	H4754_004_0	8	6	Routine Eyewear	10		17b;	2		2			2			2	
H4754	006	0	1	04	01	H4754_006_0	4	1	50% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;18a;	14b;17a;	2		1	50	50	2			2	
H4754	006	0	1	04	01	H4754_006_0	4	2	Hearing Aids	10		18a;18b;	2		2			1	699.00	999.00	2	
H4754	006	0	1	04	01	H4754_006_0	4	3	Eyewear	11	17b;	17b;	2		2			2			2	
H4754	006	0	1	04	01	H4754_006_0	4	4	Mandatory / Enhanced Benefits	10		14c;	2		2			2			2	
H4754	006	0	1	04	01	H4754_006_0	4	5	Ambulance	01	10a;		2		2			1	250.00	250.00	2	
H4754	007	0	1	04	01	H4754_007_0	7	1	50% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;18a;	14b;17a;	2		1	50	50	2			2	
H4754	007	0	1	04	01	H4754_007_0	7	2	Ambulance	01	10a;		2		2			1	200.00	200.00	2	
H4754	007	0	1	04	01	H4754_007_0	7	3	Mandatory / Enhanced Benefits	10		14c;	2		2			2			2	
H4754	007	0	1	04	01	H4754_007_0	7	4	Zero Dollar Copay	01	17b;		2		2			2			2	
H4754	007	0	1	04	01	H4754_007_0	7	5	Hearing Aids	10		18a;18b;	2		2			1	699.00	999.00	2	
H4754	007	0	1	04	01	H4754_007_0	7	6	Routine Eyewear	10		17b;	2		2			2			2	
H4754	008	0	1	04	01	H4754_008_0	4	1	50% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;11c;12;14a;14d;14e;15;16b;17a;18a;	14b;17a;	2		1	50	50	2			2	
H4754	008	0	1	04	01	H4754_008_0	4	2	Hearing Aids	10		18a;18b;	2		2			1	699.00	999.00	2	
H4754	008	0	1	04	01	H4754_008_0	4	3	Eyewear	11	17b;	17b;	2		2			2			2	
H4754	008	0	1	04	01	H4754_008_0	4	4	Mandatory / Enhanced Benefits	10		14c;	2		2			2			2	
H4754	008	0	1	04	01	H4754_008_0	4	5	Ambulance	01	10a;		2		2			1	250.00	250.00	2	
H4754	008	0	1	04	01	H4754_008_0	4	6	30% Coinsurance	01	11a;		2		1	30	30	2			2	
H4754	009	0	1	04	01	H4754_009_0	7	1	50% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;18a;	14b;17a;	2		1	50	50	2			2	
H4754	009	0	1	04	01	H4754_009_0	7	2	Ambulance	01	10a;		2		2			1	200.00	200.00	2	
H4754	009	0	1	04	01	H4754_009_0	7	3	Mandatory / Enhanced Benefits	10		14c;	2		2			2			2	
H4754	009	0	1	04	01	H4754_009_0	7	4	Zero Dollar Copay	01	17b;		2		2			2			2	
H4754	009	0	1	04	01	H4754_009_0	7	5	Hearing Aids	10		18a;18b;	2		2			1	699.00	999.00	2	
H4754	009	0	1	04	01	H4754_009_0	7	6	Routine Eyewear	10		17b;	2		2			2			2	
H4754	011	0	1	04	01	H4754_011_0	7	1	50% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;18a;	14b;17a;	2		1	50	50	2			2	
H4754	011	0	1	04	01	H4754_011_0	7	2	Ambulance	01	10a;		2		2			1	200.00	200.00	2	
H4754	011	0	1	04	01	H4754_011_0	7	3	Mandatory / Enhanced Benefits	10		14c;	2		2			2			2	
H4754	011	0	1	04	01	H4754_011_0	7	4	Zero Dollar Copay	01	17b;		2		2			2			2	
H4754	011	0	1	04	01	H4754_011_0	7	5	Hearing Aids	10		18a;18b;	2		2			1	699.00	999.00	2	
H4754	011	0	1	04	01	H4754_011_0	7	6	Routine Eyewear	10		17b;	2		2			2			2	
H4754	012	0	1	04	01	H4754_012_0	4	1	50% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;18a;	14b;17a;	2		1	50	50	2			2	
H4754	012	0	1	04	01	H4754_012_0	4	2	Hearing Aids	10		18a;18b;	2		2			1	699.00	999.00	2	
H4754	012	0	1	04	01	H4754_012_0	4	3	Eyewear	11	17b;	17b;	2		2			2			2	
H4754	012	0	1	04	01	H4754_012_0	4	4	Mandatory / Enhanced Benefits	10		14c;	2		2			2			2	
H4754	012	0	1	04	01	H4754_012_0	4	5	Ambulance	01	10a;		2		2			1	250.00	250.00	2	
H4754	801	0	1	04	01	H4754_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
H4754	801	0	1	04	01	H4754_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4754	802	0	1	04	01	H4754_802_0	2	1		01	6;14a;		2		1	0	0	2			2	
H4754	802	0	1	04	01	H4754_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4875	016	1	1	04	01	H4875_016_1	4	1	30% coinsurance	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;12;14a;14d;14e;16b;17a;17b;18a;	14b;	2		1	30	30	2			2	
H4875	016	1	1	04	01	H4875_016_1	4	2	$0-$40 Copayment	10		16a;	2		2			1	0.00	40.00	2	
H4875	016	1	1	04	01	H4875_016_1	4	3	0-30% coinsurance	10		14c;	2		1	0	30	2			2	
H4875	016	1	1	04	01	H4875_016_1	4	4	20% coinsurance	01	15;		2		1	20	20	2			2	
H4875	016	1	1	04	01	H4875_016_1	4	5	$200 copayment	01	10a;		2		2			1	200.00	200.00	2	
H4875	016	1	1	04	01	H4875_016_1	4	6	$0 copayment	11	6;9d;	9d;15;	2		2			2			2	
H4875	016	1	1	04	01	H4875_016_1	4	7	40% coinsurance	01	5;		2		1	40	40	2			2	
H4875	016	2	1	04	01	H4875_016_2	4	1	30% coinsurance	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;12;14a;14d;14e;16b;17a;17b;18a;	14b;	2		1	30	30	2			2	
H4875	016	2	1	04	01	H4875_016_2	4	2	$0-$40 Copayment	10		16a;	2		2			1	0.00	40.00	2	
H4875	016	2	1	04	01	H4875_016_2	4	3	0-30% coinsurance	10		14c;	2		1	0	30	2			2	
H4875	016	2	1	04	01	H4875_016_2	4	4	20% coinsurance	01	15;		2		1	20	20	2			2	
H4875	016	2	1	04	01	H4875_016_2	4	5	$200 copayment	01	10a;		2		2			1	200.00	200.00	2	
H4875	016	2	1	04	01	H4875_016_2	4	6	$0 copayment	11	6;9d;	9d;15;	2		2			2			2	
H4875	016	2	1	04	01	H4875_016_2	4	7	40% coinsurance	01	5;		2		1	40	40	2			2	
H4875	016	3	1	04	01	H4875_016_3	4	1	30% coinsurance	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;12;14a;14d;14e;16b;17a;17b;18a;	14b;	2		1	30	30	2			2	
H4875	016	3	1	04	01	H4875_016_3	4	2	$0-$40 Copayment	10		16a;	2		2			1	0.00	40.00	2	
H4875	016	3	1	04	01	H4875_016_3	4	3	0-30% coinsurance	10		14c;	2		1	0	30	2			2	
H4875	016	3	1	04	01	H4875_016_3	4	4	20% coinsurance	01	15;		2		1	20	20	2			2	
H4875	016	3	1	04	01	H4875_016_3	4	5	$200 copayment	01	10a;		2		2			1	200.00	200.00	2	
H4875	016	3	1	04	01	H4875_016_3	4	6	$0 copayment	11	6;9d;	9d;15;	2		2			2			2	
H4875	016	3	1	04	01	H4875_016_3	4	7	40% coinsurance	01	5;		2		1	40	40	2			2	
H4875	016	4	1	04	01	H4875_016_4	4	1	30% coinsurance	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;12;14a;14d;14e;16b;17a;17b;18a;	14b;	2		1	30	30	2			2	
H4875	016	4	1	04	01	H4875_016_4	4	2	$0-$40 Copayment	10		16a;	2		2			1	0.00	40.00	2	
H4875	016	4	1	04	01	H4875_016_4	4	3	0-30% coinsurance	10		14c;	2		1	0	30	2			2	
H4875	016	4	1	04	01	H4875_016_4	4	4	20% coinsurance	01	15;		2		1	20	20	2			2	
H4875	016	4	1	04	01	H4875_016_4	4	5	$200 copayment	01	10a;		2		2			1	200.00	200.00	2	
H4875	016	4	1	04	01	H4875_016_4	4	6	$0 copayment	11	6;9d;	9d;15;	2		2			2			2	
H4875	016	4	1	04	01	H4875_016_4	4	7	40% coinsurance	01	5;		2		1	40	40	2			2	
H4875	016	5	1	04	01	H4875_016_5	4	1	30% coinsurance	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;12;14a;14d;14e;16b;17a;17b;18a;	14b;	2		1	30	30	2			2	
H4875	016	5	1	04	01	H4875_016_5	4	2	$0-$40 Copayment	10		16a;	2		2			1	0.00	40.00	2	
H4875	016	5	1	04	01	H4875_016_5	4	3	0-30% coinsurance	10		14c;	2		1	0	30	2			2	
H4875	016	5	1	04	01	H4875_016_5	4	4	20% coinsurance	01	15;		2		1	20	20	2			2	
H4875	016	5	1	04	01	H4875_016_5	4	5	$200 copayment	01	10a;		2		2			1	200.00	200.00	2	
H4875	016	5	1	04	01	H4875_016_5	4	6	$0 copayment	11	6;9d;	9d;15;	2		2			2			2	
H4875	016	5	1	04	01	H4875_016_5	4	7	40% coinsurance	01	5;		2		1	40	40	2			2	
H4875	017	1	1	04	01	H4875_017_1	4	1	30% coinsurance	11	7b;7c;7e;7f;7h;7i;8b1;8b2;8b3;9c;11a;11b;11c;12;14a;14d;14e;16b;17a;17b;18a;	14b;	2		1	30	30	2			2	
H4875	017	1	1	04	01	H4875_017_1	4	10	$25 Copayment	01	3-1;3-2;3-3;		2		2			1	25.00	25.00	2	
H4875	017	1	1	04	01	H4875_017_1	4	11	$150 Copayment	01	10a;		2		2			1	150.00	150.00	2	
H4875	017	1	1	04	01	H4875_017_1	4	12	$0-$125 Outpatient hospital	01	9a;		2		2			1	0.00	125.00	2	
H4875	017	1	1	04	01	H4875_017_1	4	2	$30 Copayment	01	8a1;8a2;		2		2			1	30.00	30.00	2	
H4875	017	1	1	04	01	H4875_017_1	4	3	20% coinsurance	01	15;		2		1	20	20	2			2	
H4875	017	1	1	04	01	H4875_017_1	4	4	0%-30% Coinsurance	10		14c;	2		1	0	30	2			2	
H4875	017	1	1	04	01	H4875_017_1	4	5	$125 Copayment	01	9b;		2		2			1	125.00	125.00	2	
H4875	017	1	1	04	01	H4875_017_1	4	6	$0 Copayment	11	6;9d;	9d;15;	2		2			2			2	
H4875	017	1	1	04	01	H4875_017_1	4	7	40% coinsurance	01	5;		2		1	40	40	2			2	
H4875	017	1	1	04	01	H4875_017_1	4	8	$0-$40 Copayment	11	7d;7g;	16a;	2		2			1	0.00	40.00	2	
H4875	017	1	1	04	01	H4875_017_1	4	9	$0-$15 Copayment	01	7a;		2		2			1	0.00	15.00	2	
H4875	017	2	1	04	01	H4875_017_2	4	1	30% coinsurance	11	7b;7c;7e;7f;7h;7i;8b1;8b2;8b3;9c;11a;11b;11c;12;14a;14d;14e;16b;17a;17b;18a;	14b;	2		1	30	30	2			2	
H4875	017	2	1	04	01	H4875_017_2	4	10	$25 Copayment	01	3-1;3-2;3-3;		2		2			1	25.00	25.00	2	
H4875	017	2	1	04	01	H4875_017_2	4	11	$150 Copayment	01	10a;		2		2			1	150.00	150.00	2	
H4875	017	2	1	04	01	H4875_017_2	4	12	$0-$125 Outpatient hospital	01	9a;		2		2			1	0.00	125.00	2	
H4875	017	2	1	04	01	H4875_017_2	4	2	$30 Copayment	01	8a1;8a2;		2		2			1	30.00	30.00	2	
H4875	017	2	1	04	01	H4875_017_2	4	3	20% coinsurance	01	15;		2		1	20	20	2			2	
H4875	017	2	1	04	01	H4875_017_2	4	4	0%-30% Coinsurance	10		14c;	2		1	0	30	2			2	
H4875	017	2	1	04	01	H4875_017_2	4	5	$125 Copayment	01	9b;		2		2			1	125.00	125.00	2	
H4875	017	2	1	04	01	H4875_017_2	4	6	$0 Copayment	11	6;9d;	9d;15;	2		2			2			2	
H4875	017	2	1	04	01	H4875_017_2	4	7	40% coinsurance	01	5;		2		1	40	40	2			2	
H4875	017	2	1	04	01	H4875_017_2	4	8	$0-$40 Copayment	11	7d;7g;	16a;	2		2			1	0.00	40.00	2	
H4875	017	2	1	04	01	H4875_017_2	4	9	$0-$15 Copayment	01	7a;		2		2			1	0.00	15.00	2	
H4875	017	3	1	04	01	H4875_017_3	4	1	30% coinsurance	11	7b;7c;7e;7f;7h;7i;8b1;8b2;8b3;9c;11a;11b;11c;12;14a;14d;14e;16b;17a;17b;18a;	14b;	2		1	30	30	2			2	
H4875	017	3	1	04	01	H4875_017_3	4	10	$25 Copayment	01	3-1;3-2;3-3;		2		2			1	25.00	25.00	2	
H4875	017	3	1	04	01	H4875_017_3	4	11	$150 Copayment	01	10a;		2		2			1	150.00	150.00	2	
H4875	017	3	1	04	01	H4875_017_3	4	12	$0-$125 Outpatient hospital	01	9a;		2		2			1	0.00	125.00	2	
H4875	017	3	1	04	01	H4875_017_3	4	2	$30 Copayment	01	8a1;8a2;		2		2			1	30.00	30.00	2	
H4875	017	3	1	04	01	H4875_017_3	4	3	20% coinsurance	01	15;		2		1	20	20	2			2	
H4875	017	3	1	04	01	H4875_017_3	4	4	0%-30% Coinsurance	10		14c;	2		1	0	30	2			2	
H4875	017	3	1	04	01	H4875_017_3	4	5	$125 Copayment	01	9b;		2		2			1	125.00	125.00	2	
H4875	017	3	1	04	01	H4875_017_3	4	6	$0 Copayment	11	6;9d;	9d;15;	2		2			2			2	
H4875	017	3	1	04	01	H4875_017_3	4	7	40% coinsurance	01	5;		2		1	40	40	2			2	
H4875	017	3	1	04	01	H4875_017_3	4	8	$0-$40 Copayment	11	7d;7g;	16a;	2		2			1	0.00	40.00	2	
H4875	017	3	1	04	01	H4875_017_3	4	9	$0-$15 Copayment	01	7a;		2		2			1	0.00	15.00	2	
H4875	017	4	1	04	01	H4875_017_4	4	1	30% coinsurance	11	7b;7c;7e;7f;7h;7i;8b1;8b2;8b3;9c;11a;11b;11c;12;14a;14d;14e;16b;17a;17b;18a;	14b;	2		1	30	30	2			2	
H4875	017	4	1	04	01	H4875_017_4	4	10	$25 Copayment	01	3-1;3-2;3-3;		2		2			1	25.00	25.00	2	
H4875	017	4	1	04	01	H4875_017_4	4	11	$150 Copayment	01	10a;		2		2			1	150.00	150.00	2	
H4875	017	4	1	04	01	H4875_017_4	4	12	$0-$125 Outpatient hospital	01	9a;		2		2			1	0.00	125.00	2	
H4875	017	4	1	04	01	H4875_017_4	4	2	$30 Copayment	01	8a1;8a2;		2		2			1	30.00	30.00	2	
H4875	017	4	1	04	01	H4875_017_4	4	3	20% coinsurance	01	15;		2		1	20	20	2			2	
H4875	017	4	1	04	01	H4875_017_4	4	4	0%-30% Coinsurance	10		14c;	2		1	0	30	2			2	
H4875	017	4	1	04	01	H4875_017_4	4	5	$125 Copayment	01	9b;		2		2			1	125.00	125.00	2	
H4875	017	4	1	04	01	H4875_017_4	4	6	$0 Copayment	11	6;9d;	9d;15;	2		2			2			2	
H4875	017	4	1	04	01	H4875_017_4	4	7	40% coinsurance	01	5;		2		1	40	40	2			2	
H4875	017	4	1	04	01	H4875_017_4	4	8	$0-$40 Copayment	11	7d;7g;	16a;	2		2			1	0.00	40.00	2	
H4875	017	4	1	04	01	H4875_017_4	4	9	$0-$15 Copayment	01	7a;		2		2			1	0.00	15.00	2	
H4875	017	5	1	04	01	H4875_017_5	4	1	30% coinsurance	11	7b;7c;7e;7f;7h;7i;8b1;8b2;8b3;9c;11a;11b;11c;12;14a;14d;14e;16b;17a;17b;18a;	14b;	2		1	30	30	2			2	
H4875	017	5	1	04	01	H4875_017_5	4	10	$25 Copayment	01	3-1;3-2;3-3;		2		2			1	25.00	25.00	2	
H4875	017	5	1	04	01	H4875_017_5	4	11	$150 Copayment	01	10a;		2		2			1	150.00	150.00	2	
H4875	017	5	1	04	01	H4875_017_5	4	12	$0-$125 Outpatient hospital	01	9a;		2		2			1	0.00	125.00	2	
H4875	017	5	1	04	01	H4875_017_5	4	2	$30 Copayment	01	8a1;8a2;		2		2			1	30.00	30.00	2	
H4875	017	5	1	04	01	H4875_017_5	4	3	20% coinsurance	01	15;		2		1	20	20	2			2	
H4875	017	5	1	04	01	H4875_017_5	4	4	0%-30% Coinsurance	10		14c;	2		1	0	30	2			2	
H4875	017	5	1	04	01	H4875_017_5	4	5	$125 Copayment	01	9b;		2		2			1	125.00	125.00	2	
H4875	017	5	1	04	01	H4875_017_5	4	6	$0 Copayment	11	6;9d;	9d;15;	2		2			2			2	
H4875	017	5	1	04	01	H4875_017_5	4	7	40% coinsurance	01	5;		2		1	40	40	2			2	
H4875	017	5	1	04	01	H4875_017_5	4	8	$0-$40 Copayment	11	7d;7g;	16a;	2		2			1	0.00	40.00	2	
H4875	017	5	1	04	01	H4875_017_5	4	9	$0-$15 Copayment	01	7a;		2		2			1	0.00	15.00	2	
H4875	018	1	1	04	01	H4875_018_1	6	1	45% coinsurance	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11c;12;14a;14d;14e;16b;17a;17b;18a;	14b;	2		1	45	45	2			2	
H4875	018	1	1	04	01	H4875_018_1	6	2	$0 copayment	11	6;9d;	9d;15;	2		2			1	0.00	0.00	2	
H4875	018	1	1	04	01	H4875_018_1	6	3	30% coinsurance	01	11a;11b;		2		1	30	30	2			2	
H4875	018	1	1	04	01	H4875_018_1	6	4	0%-45% coinsurance	10		14c;	2		1	0	45	2			2	
H4875	018	1	1	04	01	H4875_018_1	6	5	20% coinsurance	01	15;		2		1	20	20	2			2	
H4875	018	1	1	04	01	H4875_018_1	6	6	$200 copayment	01	10a;		2		2			1	200.00	200.00	2	
H4875	018	1	1	04	01	H4875_018_1	6	7	40% Coinsurance	01	5;		2		1	40	40	2			2	
H4875	018	2	1	04	01	H4875_018_2	4	1	45% coinsurance	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11c;12;14a;14d;14e;16b;17a;17b;18a;	14b;	2		1	45	45	2			2	
H4875	018	2	1	04	01	H4875_018_2	4	2	$0 copayment	11	6;9d;	9d;15;	2		2			1	0.00	0.00	2	
H4875	018	2	1	04	01	H4875_018_2	4	3	30% coinsurance	01	11a;11b;		2		1	30	30	2			2	
H4875	018	2	1	04	01	H4875_018_2	4	4	0%-45% coinsurance	10		14c;	2		1	0	45	2			2	
H4875	018	2	1	04	01	H4875_018_2	4	5	20% coinsurance	01	15;		2		1	20	20	2			2	
H4875	018	2	1	04	01	H4875_018_2	4	6	$200 copayment	01	10a;		2		2			1	200.00	200.00	2	
H4875	018	2	1	04	01	H4875_018_2	4	7	40% Coinsurance	01	5;		2		1	40	40	2			2	
H4875	018	3	1	04	01	H4875_018_3	4	1	45% coinsurance	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11c;12;14a;14d;14e;16b;17a;17b;18a;	14b;	2		1	45	45	2			2	
H4875	018	3	1	04	01	H4875_018_3	4	2	$0 copayment	11	6;9d;	9d;15;	2		2			1	0.00	0.00	2	
H4875	018	3	1	04	01	H4875_018_3	4	3	30% coinsurance	01	11a;11b;		2		1	30	30	2			2	
H4875	018	3	1	04	01	H4875_018_3	4	4	0%-45% coinsurance	10		14c;	2		1	0	45	2			2	
H4875	018	3	1	04	01	H4875_018_3	4	5	20% coinsurance	01	15;		2		1	20	20	2			2	
H4875	018	3	1	04	01	H4875_018_3	4	6	$200 copayment	01	10a;		2		2			1	200.00	200.00	2	
H4875	018	3	1	04	01	H4875_018_3	4	7	40% Coinsurance	01	5;		2		1	40	40	2			2	
H4875	018	4	1	04	01	H4875_018_4	4	1	45% coinsurance	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11c;12;14a;14d;14e;16b;17a;17b;18a;	14b;	2		1	45	45	2			2	
H4875	018	4	1	04	01	H4875_018_4	4	2	$0 copayment	11	6;9d;	9d;15;	2		2			1	0.00	0.00	2	
H4875	018	4	1	04	01	H4875_018_4	4	3	30% coinsurance	01	11a;11b;		2		1	30	30	2			2	
H4875	018	4	1	04	01	H4875_018_4	4	4	0%-45% coinsurance	10		14c;	2		1	0	45	2			2	
H4875	018	4	1	04	01	H4875_018_4	4	5	20% coinsurance	01	15;		2		1	20	20	2			2	
H4875	018	4	1	04	01	H4875_018_4	4	6	$200 copayment	01	10a;		2		2			1	200.00	200.00	2	
H4875	018	4	1	04	01	H4875_018_4	4	7	40% Coinsurance	01	5;		2		1	40	40	2			2	
H4875	018	5	1	04	01	H4875_018_5	4	1	45% coinsurance	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11c;12;14a;14d;14e;16b;17a;17b;18a;	14b;	2		1	45	45	2			2	
H4875	018	5	1	04	01	H4875_018_5	4	2	$0 copayment	11	6;9d;	9d;15;	2		2			1	0.00	0.00	2	
H4875	018	5	1	04	01	H4875_018_5	4	3	30% coinsurance	01	11a;11b;		2		1	30	30	2			2	
H4875	018	5	1	04	01	H4875_018_5	4	4	0%-45% coinsurance	10		14c;	2		1	0	45	2			2	
H4875	018	5	1	04	01	H4875_018_5	4	5	20% coinsurance	01	15;		2		1	20	20	2			2	
H4875	018	5	1	04	01	H4875_018_5	4	6	$200 copayment	01	10a;		2		2			1	200.00	200.00	2	
H4875	018	5	1	04	01	H4875_018_5	4	7	40% Coinsurance	01	5;		2		1	40	40	2			2	
H4875	803	0	1	04	01	H4875_803_0	4	1	20% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;15;16b;17b;18a;	14b;14c;	2		1	20	20	2			2	
H4875	803	0	1	04	01	H4875_803_0	4	2	20% Coinsurance (+ physician coins)	01	8a1;8b1;8b2;8b3;14e;17a;		2		1	20	20	2			2	
H4875	804	0	1	04	01	H4875_804_0	3	1	20% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;15;16b;17b;18a;	14b;14c;	2		1	20	20	2			2	
H4875	804	0	1	04	01	H4875_804_0	3	2	20% Coinsurance (+ physician coins)	01	8a1;8b1;8b2;8b3;14e;17a;		2		1	20	20	2			2	
H4876	001	0	1	04	01	H4876_001_0	8	1	Out-of-Network services	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	13a;16a;17a;	2		1	20	20	2			2	
H4876	001	0	1	04	01	H4876_001_0	8	2	Out-of-Network OTC benefits	10		13b;	1	37.00	2			2			2	
H4876	001	0	1	04	01	H4876_001_0	8	3		10		18b;	2		2			2			2	
H4876	001	0	1	04	01	H4876_001_0	8	4		10		16b;	1	1000.00	2			2			2	
H4876	001	0	1	04	01	H4876_001_0	8	5		10		17b;	2		1	20	20	2			2	
H4876	001	0	1	04	01	H4876_001_0	8	6		10		14c;	1	25.00	1	20	20	2			2	
H4876	003	0	1	04	01	H4876_003_0	9	1	Out--of-Network Services	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	10b;13a;16a;17a;	2		1	20	20	2			2	
H4876	003	0	1	04	01	H4876_003_0	9	2	Out-of-Network OTC Benefits	10		13b;	1	38.00	2			2			2	
H4876	003	0	1	04	01	H4876_003_0	9	3		10		18b;	2		2			2			2	
H4876	003	0	1	04	01	H4876_003_0	9	4		10		16b;	2		2			2			2	
H4876	003	0	1	04	01	H4876_003_0	9	5		10		17b;	2		1	20	20	2			2	
H4876	003	0	1	04	01	H4876_003_0	9	6		10		14c;	1	25.00	1	20	20	2			2	
H4876	801	0	1	04	01	H4876_801_0	5	1		01	6;14a;		2		1	0	0	2			2	
H4876	801	0	1	04	01	H4876_801_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4876	802	0	1	04	01	H4876_802_0	3	1		01	6;14a;		2		1	0	0	2			2	
H4876	802	0	1	04	01	H4876_802_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4882	001	0	1	04	01	H4882_001_0	10	1	Benefits with OON Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	9d;13a;14b;17a;18a;	2		1	40	40	2			2	
H4882	001	0	1	04	01	H4882_001_0	10	2	Ambulance Services OON	01	10a;		2		1	20	20	2			2	
H4882	001	0	1	04	01	H4882_001_0	10	3	Dialysis Services OON	01	12;		2		2			2			2	
H4882	001	0	1	04	01	H4882_001_0	10	4	US emergency travel logistics	10		13d;	2		1	40	40	2			2	
H4882	001	0	1	04	01	H4882_001_0	10	5	Benefits with OON Coinsurance Range	10		14c;	2		1	40	50	2			2	
H4882	801	0	1	04	01	H4882_801_0	3	1	OON Benefits	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;		2		1	50	50	2			2	
H4882	803	0	1	04	01	H4882_803_0	3	1	OON Benefits	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;		2		1	50	50	2			2	
H4909	014	0	1	04	01	H4909_014_0	4	1	35%	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14d;14e;17a;17b;18a;		2		1	35	35	2			2	
H4909	014	0	1	04	01	H4909_014_0	4	10	14C Eligible Supplemental Benefits	10		14c;	1	95.00	2			1	0.00	0.00	2	
H4909	014	0	1	04	01	H4909_014_0	4	2	$30	11	7a;7g;	14b;	2		2			1	30.00	30.00	2	
H4909	014	0	1	04	01	H4909_014_0	4	3	$50	01	7b;7c;7d;7e;7f;7h;7i;		2		2			1	50.00	50.00	2	
H4909	014	0	1	04	01	H4909_014_0	4	4	30%	01	8a1;8a2;8b1;8b3;		2		1	30	30	2			2	
H4909	014	0	1	04	01	H4909_014_0	4	5	20%	11	8b2;12;	16a;	2		1	20	20	2			2	
H4909	014	0	1	04	01	H4909_014_0	4	6	$0	11	9d;16b;	9d;17a;	2		2			1	0.00	0.00	2	
H4909	014	0	1	04	01	H4909_014_0	4	7	20% - $150	01	10a;		2		1	20	20	1	150.00	150.00	2	
H4909	014	0	1	04	01	H4909_014_0	4	8	35%	01	14a;		2		1	35	35	2			2	
H4909	014	0	1	04	01	H4909_014_0	4	9	25%	01	15;		2		1	25	25	2			2	
H4909	015	0	1	04	01	H4909_015_0	5	1	$0	11	9d;16b;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H4909	015	0	1	04	01	H4909_015_0	5	2	20%	11	8b2;12;	16a;18a;	2		1	20	20	2			2	
H4909	015	0	1	04	01	H4909_015_0	5	3	Ambulance	01	10a;		2		1	20	20	1	295.00	295.00	2	
H4909	015	0	1	04	01	H4909_015_0	5	4	Diag/Rad	01	8a1;8b1;8b3;		2		1	35	35	2			2	
H4909	015	0	1	04	01	H4909_015_0	5	5	PCP	01	7a;7g;		2		2			1	40.00	40.00	2	
H4909	015	0	1	04	01	H4909_015_0	5	6	SPEC	11	7b;7c;7d;7e;7f;7h;7i;	7f;14b;	2		2			1	60.00	60.00	2	
H4909	015	0	1	04	01	H4909_015_0	5	7	General	01	3-1;3-2;3-3;5;6;8a2;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;		2		1	40	40	2			2	
H4909	015	0	1	04	01	H4909_015_0	5	8	$0	10		14c;	1	95.00	2			1	0.00	0.00	2	
H4909	015	0	1	04	01	H4909_015_0	5	9	50%	10		18b;	2		1	50	50	2			2	
H4909	804	0	1	04	01	H4909_804_0	1	1		01	6;14a;		2		1	0	0	2			2	
H4909	804	0	1	04	01	H4909_804_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4909	805	0	1	04	01	H4909_805_0	1	1		01	6;14a;		2		1	0	0	2			2	
H4909	805	0	1	04	01	H4909_805_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4909	806	0	1	04	01	H4909_806_0	1	1		01	6;14a;		2		1	0	0	2			2	
H4909	806	0	1	04	01	H4909_806_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4909	810	0	2	04	01	H4909_810_0	1	1		01	6;14a;		2		1	0	0	2			2	
H4909	810	0	2	04	01	H4909_810_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H4909	811	0	1	04	01	H4909_811_0	1	1		01	6;14a;		2		1	0	0	2			2	
H4909	811	0	1	04	01	H4909_811_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5009	001	0	1	04	01	H5009_001_0	8	1	Routine Eye Exam and Eyewear	10		17a;17b;	2		2			1	0.00	0.00	2	
H5009	001	0	1	04	01	H5009_001_0	8	2	Eligible Supplemental Benefits	10		14c;	2		2			1	0.00	0.00	2	
H5009	001	0	1	04	01	H5009_001_0	8	3	Ambulance Services	01	10a;		2		2			1	275.00	275.00	2	
H5009	001	0	1	04	01	H5009_001_0	8	4	All Other OON 50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;16a;	2		1	50	50	2			2	
H5009	002	0	1	04	01	H5009_002_0	9	1	Routine Eye Exam and Eyewear	10		17a;17b;	2		2			1	0.00	0.00	2	
H5009	002	0	1	04	01	H5009_002_0	9	2	Eligible Supplemental Benefits	10		14c;	2		2			1	0.00	0.00	2	
H5009	002	0	1	04	01	H5009_002_0	9	3	Ambulance Services	01	10a;		2		2			1	275.00	275.00	2	
H5009	002	0	1	04	01	H5009_002_0	9	4	All Other OON 50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;16a;	2		1	50	50	2			2	
H5009	008	0	1	04	01	H5009_008_0	8	1	Eligible Supplemental Benefits	10		14c;	2		2			1	0.00	0.00	2	
H5009	008	0	1	04	01	H5009_008_0	8	2	Ambulance Services	01	10a;		2		2			1	275.00	275.00	2	
H5009	008	0	1	04	01	H5009_008_0	8	3	All Other OON 50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;	2		1	50	50	2			2	
H5009	801	0	1	04	01	H5009_801_0	3	1		01	6;14a;		2		1	0	0	2			2	
H5009	801	0	1	04	01	H5009_801_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5009	802	0	1	04	01	H5009_802_0	3	1		01	6;14a;		2		1	0	0	2			2	
H5009	802	0	1	04	01	H5009_802_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5010	001	0	1	04	01	H5010_001_0	8	1	Routine Eye Exam and Eyewear	10		17a;17b;	2		2			1	0.00	0.00	2	
H5010	001	0	1	04	01	H5010_001_0	8	2	Eligible Supplemental Benefits	10		14c;	2		2			1	0.00	0.00	2	
H5010	001	0	1	04	01	H5010_001_0	8	3	Ambulance Services	01	10a;		2		2			1	275.00	275.00	2	
H5010	001	0	1	04	01	H5010_001_0	8	4	All Other OON 50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;16a;	2		1	50	50	2			2	
H5010	002	0	1	04	01	H5010_002_0	10	1	Routine Eye Exam and Eyewear	10		17a;17b;	2		2			1	0.00	0.00	2	
H5010	002	0	1	04	01	H5010_002_0	10	2	Eligible Supplemental Benefits	10		14c;	2		2			1	0.00	0.00	2	
H5010	002	0	1	04	01	H5010_002_0	10	3	Ambulance Services	01	10a;		2		2			1	275.00	275.00	2	
H5010	002	0	1	04	01	H5010_002_0	10	4	All Other OON 50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;16a;	2		1	50	50	2			2	
H5010	004	0	1	04	01	H5010_004_0	8	1	Routine Eye Exam and Eyewear	10		17a;17b;	2		2			1	0.00	0.00	2	
H5010	004	0	1	04	01	H5010_004_0	8	2	Eligible Supplemental Benefits	10		14c;	2		2			1	0.00	0.00	2	
H5010	004	0	1	04	01	H5010_004_0	8	3	Ambulance Services	01	10a;		2		2			1	250.00	250.00	2	
H5010	004	0	1	04	01	H5010_004_0	8	4	All Other OON 50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;16a;16b;	2		1	50	50	2			2	
H5010	004	0	1	04	01	H5010_004_0	8	5	Hearing Exams	10		18a;	2		2			1	150.00	150.00	2	
H5010	004	0	1	04	01	H5010_004_0	8	6	Hearing Aids	10		18b;	2		2			1	599.00	899.00	2	
H5042	801	0	1	04	01	H5042_801_0	4	1		01	6;14a;		2		1	0	0	2			2	
H5042	801	0	1	04	01	H5042_801_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5042	802	0	1	04	01	H5042_802_0	4	1		01	6;14a;		2		1	0	0	2			2	
H5042	802	0	1	04	01	H5042_802_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5042	803	0	1	04	01	H5042_803_0	4	1		01	6;14a;		2		1	0	0	2			2	
H5042	803	0	1	04	01	H5042_803_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5106	013	0	1	04	01	H5106_013_0	10	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;16b;18a;	7b;7f;9d;18a;	2		1	30	30	2			2	
H5106	013	0	1	04	01	H5106_013_0	10	10	Routine Eye Exams	10		17a;	2		2			1	50.00	50.00	2	
H5106	013	0	1	04	01	H5106_013_0	10	11	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H5106	013	0	1	04	01	H5106_013_0	10	2	Preventive Services and Routine Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2			2	
H5106	013	0	1	04	01	H5106_013_0	10	3	Ambulance	01	10a;		2		1	30	30	1	175.00	175.00	2	
H5106	013	0	1	04	01	H5106_013_0	10	4	Transportation and Preventive Dental	10		10b;16a;	2		1	50	50	2			2	
H5106	013	0	1	04	01	H5106_013_0	10	5	Fitness Benefit	10		14c;	2		1	50	50	2			1	500.00
H5106	013	0	1	04	01	H5106_013_0	10	6	Primary Care Physician	01	7a;		2		2			1	30.00	30.00	2	
H5106	013	0	1	04	01	H5106_013_0	10	7	Specialist and NonRoutine Eye Exam	01	7d;17a;		2		2			1	45.00	45.00	2	
H5106	013	0	1	04	01	H5106_013_0	10	8	End Stage Renal Disease	01	12;		2		1	20	30	2			2	
H5106	013	0	1	04	01	H5106_013_0	10	9	Medicare Part B Rx Drugs	01	15;		2		1	30	30	2			2	
H5106	806	0	1	04	01	H5106_806_0	8	1		01	6;14a;		2		1	0	0	2			2	
H5106	806	0	1	04	01	H5106_806_0	8	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5106	807	0	1	04	01	H5106_807_0	8	1		01	6;14a;		2		1	0	0	2			2	
H5106	807	0	1	04	01	H5106_807_0	8	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5106	808	0	1	04	01	H5106_808_0	8	1		01	6;14a;		2		1	0	0	2			2	
H5106	808	0	1	04	01	H5106_808_0	8	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5141	001	0	1	04	01	H5141_001_0	8	1	ASC, Observation, Outpatient Services	01	9a;9b;		2		2			1	90.00	290.00	2	
H5141	001	0	1	04	01	H5141_001_0	8	10	Eligible Supplemental Benefits	10		14c;	2		2			2			2	
H5141	001	0	1	04	01	H5141_001_0	8	11	Supplemental Hearing	10		18a;18b;	2		2			1	0.00	999.00	2	
H5141	001	0	1	04	01	H5141_001_0	8	12	Preventive Dental	10		16a;	2		2			2			2	
H5141	001	0	1	04	01	H5141_001_0	8	13	Diagnostic Procedures/ Lab Services	01	8a1;8a2;		2		2			1	0.00	150.00	2	
H5141	001	0	1	04	01	H5141_001_0	8	2	Coinsurance - 20%	01	11a;11b;12;15;		2		1	20	20	2			2	
H5141	001	0	1	04	01	H5141_001_0	8	3	MRI, PET, CT, Nuclear Medicine	01	8b1;		2		2			1	30.00	150.00	2	
H5141	001	0	1	04	01	H5141_001_0	8	4	Therapeutic Radiological Services, X-Ray	01	8b2;8b3;		2		2			1	30.00	30.00	2	
H5141	001	0	1	04	01	H5141_001_0	8	5	Specialist and Rehabilitation	01	3-1;3-2;3-3;5;7c;7d;7e;7f;7h;7i;9c;17a;18a;		2		2			1	25.00	25.00	2	
H5141	001	0	1	04	01	H5141_001_0	8	6	Chiro and Other Healthcare Professional	01	7b;7g;		2		2			1	0.00	25.00	2	
H5141	001	0	1	04	01	H5141_001_0	8	7	Copayment $0	11	6;7a;9d;11c;14a;14d;14e;16b;17b;	9d;	2		2			2			2	
H5141	001	0	1	04	01	H5141_001_0	8	8	Routine Eye Exams & Supplemental Eyewear	10		17a;17b;	2		2			2			2	
H5141	001	0	1	04	01	H5141_001_0	8	9	Ambulance Services	01	10a;		2		2			1	200.00	200.00	2	
H5141	004	0	1	04	01	H5141_004_0	8	1	ASC, Observation, Outpatient Services	01	9a;9b;		2		2			1	90.00	325.00	2	
H5141	004	0	1	04	01	H5141_004_0	8	10	Eligible Supplemental Benefits	10		14c;	2		2			2			2	
H5141	004	0	1	04	01	H5141_004_0	8	11	Supplemental Hearing	10		18a;18b;	2		2			1	0.00	999.00	2	
H5141	004	0	1	04	01	H5141_004_0	8	12	Preventive Dental	10		16a;	2		2			2			2	
H5141	004	0	1	04	01	H5141_004_0	8	13	Diagnostic Procedures/ Lab Services	01	8a1;8a2;		2		2			1	0.00	150.00	2	
H5141	004	0	1	04	01	H5141_004_0	8	2	Coinsurance - 20%	01	11a;11b;12;15;		2		1	20	20	2			2	
H5141	004	0	1	04	01	H5141_004_0	8	3	MRI, PET, CT, Nuclear Medicine	01	8b1;		2		2			1	30.00	150.00	2	
H5141	004	0	1	04	01	H5141_004_0	8	4	Therapeutic Radiological Services, X-Ray	01	8b2;8b3;		2		2			1	30.00	30.00	2	
H5141	004	0	1	04	01	H5141_004_0	8	5	Specialist and Rehabilitation	01	3-1;3-2;3-3;5;7c;7d;7e;7f;7h;7i;9c;17a;18a;		2		2			1	25.00	25.00	2	
H5141	004	0	1	04	01	H5141_004_0	8	6	Chiro and Other Healthcare Professional	01	7b;7g;		2		2			1	0.00	25.00	2	
H5141	004	0	1	04	01	H5141_004_0	8	7	Copayment $0	11	6;7a;9d;11c;14a;14d;14e;16b;17b;	9d;	2		2			2			2	
H5141	004	0	1	04	01	H5141_004_0	8	8	Routine Eye Exams & Supplemental Eyewear	10		17a;17b;	2		2			2			2	
H5141	004	0	1	04	01	H5141_004_0	8	9	Ambulance Services	01	10a;		2		2			1	250.00	250.00	2	
H5141	007	0	1	04	01	H5141_007_0	10	1	ASC, Observation, Outpatient Services	01	9a;9b;		2		2			1	90.00	175.00	2	
H5141	007	0	1	04	01	H5141_007_0	10	10	Eligible Supplemental Benefits	10		14c;	2		2			2			2	
H5141	007	0	1	04	01	H5141_007_0	10	11	Supplemental Hearing	10		18a;18b;	2		2			1	0.00	999.00	2	
H5141	007	0	1	04	01	H5141_007_0	10	12	Supplemental Dental	10		16a;	2		2			2			2	
H5141	007	0	1	04	01	H5141_007_0	10	13	Diagnostic Procedures/ Lab Services	01	8a1;8a2;		2		2			1	0.00	150.00	2	
H5141	007	0	1	04	01	H5141_007_0	10	14	Other Healthcare Professional	01	7g;		2		2			1	0.00	5.00	2	
H5141	007	0	1	04	01	H5141_007_0	10	2	Coinsurance- 20%	01	11a;11b;12;15;		2		1	20	20	2			2	
H5141	007	0	1	04	01	H5141_007_0	10	3	MRI, PET, CT, Nuclear Medicine	01	8b1;		2		2			1	30.00	150.00	2	
H5141	007	0	1	04	01	H5141_007_0	10	4	Therapeutic Radiological Services, X-Ray	01	8b2;8b3;		2		2			1	30.00	30.00	2	
H5141	007	0	1	04	01	H5141_007_0	10	5	Specialist and Mental Health	01	5;7d;7e;7f;7h;9c;17a;18a;		2		2			1	5.00	5.00	2	
H5141	007	0	1	04	01	H5141_007_0	10	6	Chiro and Rehabilitation Service	01	3-1;3-2;3-3;7b;7c;7i;		2		2			1	10.00	10.00	2	
H5141	007	0	1	04	01	H5141_007_0	10	7	Copayment $0	11	6;7a;9d;11c;14a;14d;14e;16b;17b;	9d;	2		2			2			2	
H5141	007	0	1	04	01	H5141_007_0	10	8	Supplemental Eye Exams and Eyewear	10		17a;17b;	2		2			1	0.00	20.00	2	
H5141	007	0	1	04	01	H5141_007_0	10	9	Ambulance Services	01	10a;		2		2			1	200.00	200.00	2	
H5141	025	0	1	04	01	H5141_025_0	8	1	Coinsurance - 45%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11c;12;14a;14d;14e;15;16b;17a;18a;	9d;	2		1	45	45	2			2	
H5141	025	0	1	04	01	H5141_025_0	8	2	Supplemental Hearing	10		18a;18b;	2		2			1	0.00	999.00	2	
H5141	025	0	1	04	01	H5141_025_0	8	3	Eligible Supplemental Benefits	10		14c;	2		2			2			2	
H5141	025	0	1	04	01	H5141_025_0	8	4	Preventive Dental	10		16a;	2		2			2			2	
H5141	025	0	1	04	01	H5141_025_0	8	5	Routine Eye Exams & Supplemental Eyewear	10		17a;17b;	2		2			2			2	
H5141	025	0	1	04	01	H5141_025_0	8	6	Coinsurance - 20%	01	11a;11b;17b;		2		1	20	20	2			2	
H5141	025	0	1	04	01	H5141_025_0	8	7	Ambulance Services	01	10a;		2		2			1	300.00	300.00	2	
H5141	026	0	1	04	01	H5141_026_0	8	1	Coinsurance - 35%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11c;12;14a;14d;14e;15;16b;17a;18a;	9d;	2		1	35	35	2			2	
H5141	026	0	1	04	01	H5141_026_0	8	2	Supplemental Hearing	10		18a;18b;	2		2			1	0.00	999.00	2	
H5141	026	0	1	04	01	H5141_026_0	8	3	Eligible Supplemental Benefits	10		14c;	2		2			2			2	
H5141	026	0	1	04	01	H5141_026_0	8	4	Preventive Dental	10		16a;	2		2			2			2	
H5141	026	0	1	04	01	H5141_026_0	8	5	Routine Eye Exams & Supplemental Eyewear	10		17a;17b;	2		2			2			2	
H5141	026	0	1	04	01	H5141_026_0	8	6	Coinsurance - 20%	01	11a;11b;17b;		2		1	20	20	2			2	
H5141	026	0	1	04	01	H5141_026_0	8	7	Ambulance Services	01	10a;		2		2			1	300.00	300.00	2	
H5141	028	0	1	04	01	H5141_028_0	9	1	Coinsurance - 35%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11c;12;14a;14d;14e;15;16b;17a;18a;	9d;	2		1	35	35	2			2	
H5141	028	0	1	04	01	H5141_028_0	9	2	Supplemental Hearing	10		18a;18b;	2		2			1	0.00	999.00	2	
H5141	028	0	1	04	01	H5141_028_0	9	3	Eligible Supplemental Benefits	10		14c;	2		2			2			2	
H5141	028	0	1	04	01	H5141_028_0	9	4	Preventive Dental	10		16a;	2		2			2			2	
H5141	028	0	1	04	01	H5141_028_0	9	5	Routine Eye Exams & Supplemental Eyewear	10		17a;17b;	2		2			2			2	
H5141	028	0	1	04	01	H5141_028_0	9	6	Coinsurance - 20%	01	11a;11b;17b;		2		1	20	20	2			2	
H5141	028	0	1	04	01	H5141_028_0	9	7	Ambulance Services	01	10a;		2		2			1	200.00	200.00	2	
H5141	032	0	1	04	01	H5141_032_0	9	1	ASC, Observation, Outpatient Services	01	9a;9b;		2		2			1	90.00	325.00	2	
H5141	032	0	1	04	01	H5141_032_0	9	10	Eligible Supplemental Benefits	10		14c;	2		2			2			2	
H5141	032	0	1	04	01	H5141_032_0	9	11	Hearing	10		18a;18b;	2		2			1	0.00	999.00	2	
H5141	032	0	1	04	01	H5141_032_0	9	12	Preventive Dental	10		16a;	2		2			2			2	
H5141	032	0	1	04	01	H5141_032_0	9	13	Diagnostic Procedures/ Lab Services	01	8a1;8a2;		2		2			1	0.00	150.00	2	
H5141	032	0	1	04	01	H5141_032_0	9	2	Coinsurance - 20%	01	11a;11b;12;15;		2		1	20	20	2			2	
H5141	032	0	1	04	01	H5141_032_0	9	3	MRI, PET, CT, Nuclear Medicine	01	8b1;		2		2			1	30.00	150.00	2	
H5141	032	0	1	04	01	H5141_032_0	9	4	Therapeutic Radiological Services, X-Ray	01	8b2;8b3;		2		2			1	30.00	30.00	2	
H5141	032	0	1	04	01	H5141_032_0	9	5	Specialist and Rehabilitation	01	3-1;3-2;3-3;5;7c;7d;7e;7f;7h;7i;9c;17a;18a;		2		2			1	25.00	25.00	2	
H5141	032	0	1	04	01	H5141_032_0	9	6	PCP, Chiro and Other Specialist	01	7a;7b;7g;		2		2			1	10.00	25.00	2	
H5141	032	0	1	04	01	H5141_032_0	9	7	Copayment $0	11	6;9d;11c;14a;14d;14e;16b;17b;	9d;	2		2			2			2	
H5141	032	0	1	04	01	H5141_032_0	9	8	Routine Eye Exams and Eyewear	10		17a;17b;	2		2			1	20.00	25.00	2	
H5141	032	0	1	04	01	H5141_032_0	9	9	Ambulance Services	01	10a;		2		2			1	250.00	250.00	2	
H5199	001	0	1	04	01	H5199_001_0	3	1	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14d;15;16b;	7b;	2		1	50	50	2			2	
H5199	001	0	1	04	01	H5199_001_0	3	2	$250	01	10a;		2		2			1	250.00	250.00	2	
H5199	001	0	1	04	01	H5199_001_0	3	3	$0	11	14a;14e;	14b;14c;	2		2			1	0.00	0.00	2	
H5199	001	0	1	04	01	H5199_001_0	3	4	Dental	10		16a;16b;	2		1	20	40	2			1	100.00
H5199	001	0	1	04	01	H5199_001_0	3	5	Vision	11	17a;17b;	17a;17b;	2		1	50	50	1	0.00	0.00	2	
H5199	001	0	1	04	01	H5199_001_0	3	6	Hearing	11	18a;	18a;18b;	2		1	50	50	2			2	
H5199	001	0	1	04	01	H5199_001_0	3	7	OTC	10		13b;	1	5.00	2			1	0.00	0.00	2	
H5199	002	0	1	04	01	H5199_002_0	4	1	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14d;15;16b;	7b;	2		1	50	50	2			2	
H5199	002	0	1	04	01	H5199_002_0	4	2	$250	01	10a;		2		2			1	250.00	250.00	2	
H5199	002	0	1	04	01	H5199_002_0	4	3	$0	11	14a;14e;	14b;14c;	2		2			1	0.00	0.00	2	
H5199	002	0	1	04	01	H5199_002_0	4	4	Dental	10		16a;16b;	2		1	20	40	2			1	100.00
H5199	002	0	1	04	01	H5199_002_0	4	5	Vision	11	17a;17b;	17a;17b;	2		1	50	50	1	0.00	0.00	2	
H5199	002	0	1	04	01	H5199_002_0	4	6	Hearing	11	18a;	18a;18b;	2		1	50	50	2			2	
H5199	002	0	1	04	01	H5199_002_0	4	7	OTC	10		13b;	1	5.00	2			1	0.00	0.00	2	
H5199	003	0	1	04	01	H5199_003_0	4	1	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14d;15;16b;	7b;	2		1	50	50	2			2	
H5199	003	0	1	04	01	H5199_003_0	4	2	$250	01	10a;		2		2			1	250.00	250.00	2	
H5199	003	0	1	04	01	H5199_003_0	4	3	$0	11	14a;14e;	14b;14c;	2		2			1	0.00	0.00	2	
H5199	003	0	1	04	01	H5199_003_0	4	4	Dental	10		16a;16b;	2		1	20	40	2			1	100.00
H5199	003	0	1	04	01	H5199_003_0	4	5	Vision	11	17a;17b;	17a;17b;	2		1	50	50	1	0.00	0.00	2	
H5199	003	0	1	04	01	H5199_003_0	4	6	Hearing	11	18a;	18a;18b;	2		1	50	50	2			2	
H5199	003	0	1	04	01	H5199_003_0	4	7	OTC	10		13b;	1	5.00	2			1	0.00	0.00	2	
H5199	004	0	1	04	01	H5199_004_0	4	1	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14d;15;16b;	7b;	2		1	50	50	2			2	
H5199	004	0	1	04	01	H5199_004_0	4	2	$250	01	10a;		2		2			1	250.00	250.00	2	
H5199	004	0	1	04	01	H5199_004_0	4	3	$0	11	14a;14e;	14b;14c;	2		2			1	0.00	0.00	2	
H5199	004	0	1	04	01	H5199_004_0	4	4	Dental	10		16a;16b;	2		1	20	40	2			1	100.00
H5199	004	0	1	04	01	H5199_004_0	4	5	Vision	11	17a;17b;	17a;17b;	2		1	50	50	1	0.00	0.00	2	
H5199	004	0	1	04	01	H5199_004_0	4	6	Hearing	11	18a;	18a;18b;	2		1	50	50	2			2	
H5199	004	0	1	04	01	H5199_004_0	4	7	OTC	10		13b;	1	5.00	2			1	0.00	0.00	2	
H5215	001	0	1	04	01	H5215_001_0	6	1	$0 Copay	11	6;9d;14a;14d;14e;	13d;14b;	2		2			2			2	
H5215	001	0	1	04	01	H5215_001_0	6	10	$100 Copay	01	8b1;		2		2			1	100.00	100.00	2	
H5215	001	0	1	04	01	H5215_001_0	6	11	$250 Copay	01	10a;		2		2			1	250.00	250.00	2	
H5215	001	0	1	04	01	H5215_001_0	6	12	$350 Copay	01	9a;9b;		2		2			1	350.00	350.00	2	
H5215	001	0	1	04	01	H5215_001_0	6	13	20% Coinsurance	01	11a;11b;15;		2		1	20	20	2			2	
H5215	001	0	1	04	01	H5215_001_0	6	14	$1000-$1985 Copay	10		18b;	2		2			1	1000.00	1985.00	2	
H5215	001	0	1	04	01	H5215_001_0	6	15	$0 Copay - $2640 Annual Max	10		14c;	1	2640.00	2			2			2	
H5215	001	0	1	04	01	H5215_001_0	6	2	$5-$25 Copay	01	3-1;3-2;3-3;8a1;8a2;8b3;9c;12;16b;17a;18a;		2		2			1	5.00	25.00	2	
H5215	001	0	1	04	01	H5215_001_0	6	3	$10 Copay	01	7a;11c;		2		2			1	10.00	10.00	2	
H5215	001	0	1	04	01	H5215_001_0	6	4	$15 Copay	01	7b;17b;		2		2			1	15.00	15.00	2	
H5215	001	0	1	04	01	H5215_001_0	6	5	100% Coinsurance	10		16a;	2		1	100	100	2			2	
H5215	001	0	1	04	01	H5215_001_0	6	6	$35 Copay	01	7e;7h;		2		2			1	35.00	35.00	2	
H5215	001	0	1	04	01	H5215_001_0	6	7	$40 Copay	01	7c;7d;7f;7g;7i;		2		2			1	40.00	40.00	2	
H5215	001	0	1	04	01	H5215_001_0	6	8	$45 Copay	01	5;		2		2			1	45.00	45.00	2	
H5215	001	0	1	04	01	H5215_001_0	6	9	$60 Copay	01	8b2;		2		2			1	60.00	60.00	2	
H5215	002	0	1	04	01	H5215_002_0	8	1	$0 Copay	11	6;9d;14a;14d;14e;	13d;14b;	2		2			2			2	
H5215	002	0	1	04	01	H5215_002_0	8	10	$100 Copay	01	8b1;		2		2			1	100.00	100.00	2	
H5215	002	0	1	04	01	H5215_002_0	8	11	$250 Copay	01	10a;		2		2			1	250.00	250.00	2	
H5215	002	0	1	04	01	H5215_002_0	8	12	$350 Copay	01	9a;9b;		2		2			1	350.00	350.00	2	
H5215	002	0	1	04	01	H5215_002_0	8	13	20% Coinsurance	01	11a;11b;15;		2		1	20	20	2			2	
H5215	002	0	1	04	01	H5215_002_0	8	14	$1000-$1985 Copay	10		18b;	2		2			1	1000.00	1985.00	2	
H5215	002	0	1	04	01	H5215_002_0	8	15	$0 Copay - $2640 Annual Max	10		14c;	1	2640.00	2			2			2	
H5215	002	0	1	04	01	H5215_002_0	8	2	$5-$25 Copay	01	3-1;3-2;3-3;8a1;8a2;8b3;9c;12;16b;17a;18a;		2		2			1	5.00	25.00	2	
H5215	002	0	1	04	01	H5215_002_0	8	3	$10 Copay	01	7a;11c;		2		2			1	10.00	10.00	2	
H5215	002	0	1	04	01	H5215_002_0	8	4	$15 Copay	01	7b;17b;		2		2			1	15.00	15.00	2	
H5215	002	0	1	04	01	H5215_002_0	8	5	100% Coinsurance	10		16a;	2		1	100	100	2			2	
H5215	002	0	1	04	01	H5215_002_0	8	6	$35 Copay	01	7e;7h;		2		2			1	35.00	35.00	2	
H5215	002	0	1	04	01	H5215_002_0	8	7	$40 Copay	01	7c;7d;7f;7g;7i;		2		2			1	40.00	40.00	2	
H5215	002	0	1	04	01	H5215_002_0	8	8	$45 Copay	01	5;		2		2			1	45.00	45.00	2	
H5215	002	0	1	04	01	H5215_002_0	8	9	$60 Copay	01	8b2;		2		2			1	60.00	60.00	2	
H5215	005	0	1	04	01	H5215_005_0	7	1	$0 Copay	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;16b;17a;17b;18a;	13d;14b;18a;	2		2			2			2	
H5215	005	0	1	04	01	H5215_005_0	7	2	$10 Copay	01	7d;		2		2			1	10.00	10.00	2	
H5215	005	0	1	04	01	H5215_005_0	7	3	20% Coinsurance	01	15;		2		1	20	20	2			2	
H5215	005	0	1	04	01	H5215_005_0	7	4	$0 Copay - $2650 Annual Max	10		14c;	1	2640.00	2			2			2	
H5215	005	0	1	04	01	H5215_005_0	7	5	$1000-$1985 Copay	10		18b;	2		2			1	1000.00	1985.00	2	
H5215	005	0	1	04	01	H5215_005_0	7	6	$5 Copay	01	7a;		2		2			1	5.00	5.00	2	
H5215	005	0	1	04	01	H5215_005_0	7	7	100% Coinsurance	10		16a;	2		1	100	100	2			2	
H5215	006	0	1	04	01	H5215_006_0	6	1	$0 Copay	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;16b;17a;17b;18a;	13d;14b;18a;	2		2			2			2	
H5215	006	0	1	04	01	H5215_006_0	6	2	$10 Copay	01	7d;		2		2			1	10.00	10.00	2	
H5215	006	0	1	04	01	H5215_006_0	6	3	20% Coinsurance	01	15;		2		1	20	20	2			2	
H5215	006	0	1	04	01	H5215_006_0	6	4	$0 Copay - $2650 Annual Max	10		14c;	1	2640.00	2			2			2	
H5215	006	0	1	04	01	H5215_006_0	6	5	$1000-$1985 Copay	10		18b;	2		2			1	1000.00	1985.00	2	
H5215	006	0	1	04	01	H5215_006_0	6	6	$5 Copay	01	7a;		2		2			1	5.00	5.00	2	
H5215	006	0	1	04	01	H5215_006_0	6	7	100% Coinsurance	10		16a;	2		1	100	100	2			2	
H5215	007	0	1	04	01	H5215_007_0	7	1	$0	11	6;	17a;	2		2			2			2	
H5215	007	0	1	04	01	H5215_007_0	7	2	$1000-$1985 Copay	10		18b;	2		2			1	1000.00	1985.00	2	
H5215	007	0	1	04	01	H5215_007_0	7	3	20%	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	13d;	2		1	20	20	2			2	
H5215	007	0	1	04	01	H5215_007_0	7	4	10-50%	10		16b;	2		1	10	50	2			2	
H5215	007	0	1	04	01	H5215_007_0	7	5	$0 + $510 limit	10		17b;	2		2			2			2	
H5215	007	0	1	04	01	H5215_007_0	7	6	0% + $2500 limit	10		16a;	2		2			2			2	
H5215	007	0	1	04	01	H5215_007_0	7	7	0-50% + $2640 limit	10		14c;	1	2640.00	1	0	50	2			2	
H5215	007	0	1	04	01	H5215_007_0	7	8	0% + $170 limit	10		13b;	1	170.00	2			2			2	
H5215	008	0	1	04	01	H5215_008_0	7	1	$0 Copay	11	6;9d;14a;14d;14e;17b;	13d;14b;	2		2			2			2	
H5215	008	0	1	04	01	H5215_008_0	7	10	$300 Copay	01	10a;		2		2			1	300.00	300.00	2	
H5215	008	0	1	04	01	H5215_008_0	7	11	$395 Copay	01	9a;9b;		2		2			1	395.00	395.00	2	
H5215	008	0	1	04	01	H5215_008_0	7	12	20% Coinsurance	01	8b2;11a;11b;12;15;		2		1	20	20	2			2	
H5215	008	0	1	04	01	H5215_008_0	7	13	$0 Copay - $2640 Annual Max	10		14c;	1	2640.00	2			2			2	
H5215	008	0	1	04	01	H5215_008_0	7	14	$1000-$1985 Copay	10		18b;	2		2			1	1000.00	1985.00	2	
H5215	008	0	1	04	01	H5215_008_0	7	15	$25 Copay	01	7a;		2		2			1	25.00	25.00	2	
H5215	008	0	1	04	01	H5215_008_0	7	2	$10 Copay	01	11c;		2		2			1	10.00	10.00	2	
H5215	008	0	1	04	01	H5215_008_0	7	3	$15 Copay	01	7b;18a;		2		2			1	15.00	15.00	2	
H5215	008	0	1	04	01	H5215_008_0	7	4	$20 Copay	01	8a2;		2		2			1	20.00	20.00	2	
H5215	008	0	1	04	01	H5215_008_0	7	5	$20-$40 Copay	01	3-1;3-2;3-3;8a1;8b3;		2		2			1	20.00	40.00	2	
H5215	008	0	1	04	01	H5215_008_0	7	6	$40 Copay	01	7c;7e;7h;7i;9c;		2		2			1	40.00	40.00	2	
H5215	008	0	1	04	01	H5215_008_0	7	7	$50 Copay	01	7d;7f;7g;16b;17a;		2		2			1	50.00	50.00	2	
H5215	008	0	1	04	01	H5215_008_0	7	8	$55 Copay	01	5;		2		2			1	55.00	55.00	2	
H5215	008	0	1	04	01	H5215_008_0	7	9	$150 Copay	01	8b1;		2		2			1	150.00	150.00	2	
H5215	009	0	1	04	01	H5215_009_0	7	1	$0 Copay	11	9d;14d;14e;	13d;	2		2			2			2	
H5215	009	0	1	04	01	H5215_009_0	7	10	$140 Copay	01	8b1;		2		2			1	140.00	140.00	2	
H5215	009	0	1	04	01	H5215_009_0	7	11	$275 Copay	01	10a;		2		2			1	275.00	275.00	2	
H5215	009	0	1	04	01	H5215_009_0	7	12	$395 Copay	01	9a;9b;		2		2			1	395.00	395.00	2	
H5215	009	0	1	04	01	H5215_009_0	7	13	25% Coinsurance	01	8b2;11a;11b;12;15;		2		1	25	25	2			2	
H5215	009	0	1	04	01	H5215_009_0	7	14	$0 Copay - $2640 Annual Max	10		14c;	1	2640.00	2			2			2	
H5215	009	0	1	04	01	H5215_009_0	7	15	$1000-$1985 Copay	10		18b;	2		2			1	1000.00	1985.00	2	
H5215	009	0	1	04	01	H5215_009_0	7	2	$10 Copay	01	11c;		2		2			1	10.00	10.00	2	
H5215	009	0	1	04	01	H5215_009_0	7	3	$15 Copay	11	6;14a;	14b;	2		2			1	15.00	15.00	2	
H5215	009	0	1	04	01	H5215_009_0	7	4	$20 Copay	01	7a;		2		2			1	20.00	20.00	2	
H5215	009	0	1	04	01	H5215_009_0	7	5	$25 Copay	01	17b;18a;		2		2			1	25.00	25.00	2	
H5215	009	0	1	04	01	H5215_009_0	7	6	$30 Copay	01	8a2;		2		2			1	30.00	30.00	2	
H5215	009	0	1	04	01	H5215_009_0	7	7	$30-$50 Copay	01	3-1;3-2;3-3;8a1;8b3;		2		2			1	30.00	50.00	2	
H5215	009	0	1	04	01	H5215_009_0	7	8	$50 Copay	01	7b;7c;7e;7h;7i;9c;		2		2			1	50.00	50.00	2	
H5215	009	0	1	04	01	H5215_009_0	7	9	$55 Copay	01	5;7d;7f;7g;16b;17a;		2		2			1	55.00	55.00	2	
H5215	010	0	1	04	01	H5215_010_0	7	1	$0 Copay	11	9d;14d;14e;	13d;	2		2			2			2	
H5215	010	0	1	04	01	H5215_010_0	7	10	$140 Copay	01	8b1;		2		2			1	140.00	140.00	2	
H5215	010	0	1	04	01	H5215_010_0	7	11	$250 Copay	01	10a;		2		2			1	250.00	250.00	2	
H5215	010	0	1	04	01	H5215_010_0	7	12	$395 Copay	01	9a;9b;		2		2			1	395.00	395.00	2	
H5215	010	0	1	04	01	H5215_010_0	7	13	25% Coinsurance	01	8b2;11a;11b;12;15;		2		1	25	25	2			2	
H5215	010	0	1	04	01	H5215_010_0	7	14	$1000-$1985 Copay	10		18b;	2		2			1	1000.00	1985.00	2	
H5215	010	0	1	04	01	H5215_010_0	7	15	$35 Copay	01	3-1;3-2;3-3;		2		2			1	35.00	35.00	2	
H5215	010	0	1	04	01	H5215_010_0	7	2	$10 Copay	01	11c;		2		2			1	10.00	10.00	2	
H5215	010	0	1	04	01	H5215_010_0	7	3	$15 Copay	11	6;7a;14a;	14b;	2		2			1	15.00	15.00	2	
H5215	010	0	1	04	01	H5215_010_0	7	4	$0 Copay - $2640 Annual Max	10		14c;	1	2640.00	2			2			2	
H5215	010	0	1	04	01	H5215_010_0	7	5	$25 Copay	01	8a2;17b;18a;		2		2			1	25.00	25.00	2	
H5215	010	0	1	04	01	H5215_010_0	7	6	$25-$45 Copay	01	8a1;8b3;		2		2			1	25.00	45.00	2	
H5215	010	0	1	04	01	H5215_010_0	7	7	100% Coinsurance	10		16a;	2		1	100	100	2			2	
H5215	010	0	1	04	01	H5215_010_0	7	8	$50 Copay	01	7b;7c;7e;7h;7i;9c;		2		2			1	50.00	50.00	2	
H5215	010	0	1	04	01	H5215_010_0	7	9	$55 Copay	01	5;7d;7f;7g;16b;17a;		2		2			1	55.00	55.00	2	
H5215	011	0	1	04	01	H5215_011_0	7	1	$0 Copay	11	6;9d;14a;14d;14e;17b;	13d;14b;	2		2			2			2	
H5215	011	0	1	04	01	H5215_011_0	7	10	$60 Copay	01	8b2;		2		2			1	60.00	60.00	2	
H5215	011	0	1	04	01	H5215_011_0	7	11	$125 Copay	01	8b1;		2		2			1	125.00	125.00	2	
H5215	011	0	1	04	01	H5215_011_0	7	12	$275 Copay	01	10a;		2		2			1	275.00	275.00	2	
H5215	011	0	1	04	01	H5215_011_0	7	13	20% Coinsurance	01	11a;11b;15;		2		1	20	20	2			2	
H5215	011	0	1	04	01	H5215_011_0	7	14	$1000-$1985 Copay	10		18b;	2		2			1	1000.00	1985.00	2	
H5215	011	0	1	04	01	H5215_011_0	7	15	$395 Copay	01	9a;9b;		2		2			1	395.00	395.00	2	
H5215	011	0	1	04	01	H5215_011_0	7	2	$10 Copay	01	7a;11c;18a;		2		2			1	10.00	10.00	2	
H5215	011	0	1	04	01	H5215_011_0	7	3	$15-$35 Copay	01	7b;8a1;8a2;		2		2			1	15.00	35.00	2	
H5215	011	0	1	04	01	H5215_011_0	7	4	$0 Copay - $2640 Annual Max	10		14c;	1	2640.00	2			2			2	
H5215	011	0	1	04	01	H5215_011_0	7	5	100% Coinsurance	10		16a;	2		1	100	100	2			2	
H5215	011	0	1	04	01	H5215_011_0	7	6	$25 Copay	01	3-1;3-2;3-3;		2		2			1	25.00	25.00	2	
H5215	011	0	1	04	01	H5215_011_0	7	7	$30 Copay	01	8b3;12;		2		2			1	30.00	30.00	2	
H5215	011	0	1	04	01	H5215_011_0	7	8	$40 Copay	01	7c;7e;7f;7h;7i;9c;		2		2			1	40.00	40.00	2	
H5215	011	0	1	04	01	H5215_011_0	7	9	$50 Copay	01	5;7d;7g;16b;17a;		2		2			1	50.00	50.00	2	
H5215	806	0	1	04	01	H5215_806_0	1	1		01	6;14a;		2		1	0	0	2			2	
H5215	806	0	1	04	01	H5215_806_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5215	807	0	1	04	01	H5215_807_0	1	1		01	6;14a;		2		1	0	0	2			2	
H5215	807	0	1	04	01	H5215_807_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5215	808	0	1	04	01	H5215_808_0	1	1		01	6;14a;		2		1	0	0	2			2	
H5215	808	0	1	04	01	H5215_808_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5216	001	0	1	04	01	H5216_001_0	2	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H5216	001	0	1	04	01	H5216_001_0	2	2		01	12;		2		1	20	20	2			2	
H5216	001	0	1	04	01	H5216_001_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	001	0	1	04	01	H5216_001_0	2	4		01	11a;		2		1	30	30	2			2	
H5216	001	0	1	04	01	H5216_001_0	2	5		01	11c;		2		1	30	50	2			2	
H5216	001	0	1	04	01	H5216_001_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;15;16b;17a;18a;	13c;14b;14c;16a;16b;	2		1	50	50	2			2	
H5216	001	0	1	04	01	H5216_001_0	2	7		10		13b;	1	40.00	1	50	50	2			2	
H5216	001	0	1	04	01	H5216_001_0	2	8		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	006	0	1	04	01	H5216_006_0	3	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H5216	006	0	1	04	01	H5216_006_0	3	2		01	12;		2		1	20	20	2			2	
H5216	006	0	1	04	01	H5216_006_0	3	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	006	0	1	04	01	H5216_006_0	3	4		01	11a;		2		1	30	30	2			2	
H5216	006	0	1	04	01	H5216_006_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13c;14b;14c;16a;	2		1	50	50	2			2	
H5216	006	0	1	04	01	H5216_006_0	3	6		10		13b;	1	40.00	1	50	50	2			2	
H5216	006	0	1	04	01	H5216_006_0	3	7		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	009	0	1	04	01	H5216_009_0	2	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H5216	009	0	1	04	01	H5216_009_0	2	2		01	11a;12;		2		1	20	20	2			2	
H5216	009	0	1	04	01	H5216_009_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	009	0	1	04	01	H5216_009_0	2	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13c;14b;14c;16a;16b;	2		1	50	50	2			2	
H5216	009	0	1	04	01	H5216_009_0	2	5		10		13b;	1	40.00	1	50	50	2			2	
H5216	009	0	1	04	01	H5216_009_0	2	6		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	011	0	1	04	01	H5216_011_0	3	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H5216	011	0	1	04	01	H5216_011_0	3	2		01	12;		2		1	20	20	2			2	
H5216	011	0	1	04	01	H5216_011_0	3	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	011	0	1	04	01	H5216_011_0	3	4		10		18a;18b;	2		1	25	25	2			2	
H5216	011	0	1	04	01	H5216_011_0	3	5		01	11a;		2		1	30	30	2			2	
H5216	011	0	1	04	01	H5216_011_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13c;14b;14c;16a;16b;	2		1	50	50	2			2	
H5216	011	0	1	04	01	H5216_011_0	3	7		10		13b;	1	40.00	1	50	50	2			2	
H5216	011	0	1	04	01	H5216_011_0	3	8		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	012	0	1	04	01	H5216_012_0	3	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H5216	012	0	1	04	01	H5216_012_0	3	2		01	11a;12;		2		1	20	20	2			2	
H5216	012	0	1	04	01	H5216_012_0	3	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	012	0	1	04	01	H5216_012_0	3	4		10		18a;18b;	2		1	25	25	2			2	
H5216	012	0	1	04	01	H5216_012_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13c;14b;14c;16a;16b;	2		1	50	50	2			2	
H5216	012	0	1	04	01	H5216_012_0	3	6		10		13b;	1	40.00	1	50	50	2			2	
H5216	012	0	1	04	01	H5216_012_0	3	7		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	013	0	1	04	01	H5216_013_0	2	1		11	9d;17b;	9d;17a;17b;18a;18b;	2		2			1	0.00	0.00	2	
H5216	013	0	1	04	01	H5216_013_0	2	2		01	12;		2		1	20	20	2			2	
H5216	013	0	1	04	01	H5216_013_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	013	0	1	04	01	H5216_013_0	2	4		01	11a;		2		1	45	45	2			2	
H5216	013	0	1	04	01	H5216_013_0	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13c;14b;14c;16a;16b;	2		1	50	50	2			2	
H5216	013	0	1	04	01	H5216_013_0	2	6		10		13b;	1	40.00	1	50	50	2			2	
H5216	013	0	1	04	01	H5216_013_0	2	7		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	014	0	1	04	01	H5216_014_0	2	1		11	9d;	9d;	2		2			1	0.00	0.00	2	
H5216	014	0	1	04	01	H5216_014_0	2	2		01	12;		2		1	20	20	2			2	
H5216	014	0	1	04	01	H5216_014_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	014	0	1	04	01	H5216_014_0	2	4		01	11a;		2		1	30	30	2			2	
H5216	014	0	1	04	01	H5216_014_0	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;14b;14c;	2		1	50	50	2			2	
H5216	014	0	1	04	01	H5216_014_0	2	6		10		13b;	1	25.00	1	50	50	2			2	
H5216	014	0	1	04	01	H5216_014_0	2	7		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	015	1	1	04	01	H5216_015_1	2	1		11	9d;17b;	9d;18a;	2		2			1	0.00	0.00	2	
H5216	015	1	1	04	01	H5216_015_1	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	015	1	1	04	01	H5216_015_1	2	3		01	11a;11b;11c;12;		2		1	20	20	2			2	
H5216	015	1	1	04	01	H5216_015_1	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	015	1	1	04	01	H5216_015_1	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;15;16b;17a;18a;	14b;	2		1	35	35	2			2	
H5216	015	1	1	04	01	H5216_015_1	2	6		01	14a;		2		1	35	35	1	0.00	0.00	2	
H5216	015	1	1	04	01	H5216_015_1	2	7		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	015	1	1	04	01	H5216_015_1	2	8		10		13b;	1	30.00	1	50	50	2			2	
H5216	015	2	1	04	01	H5216_015_2	2	1		11	9d;17b;	9d;18a;	2		2			1	0.00	0.00	2	
H5216	015	2	1	04	01	H5216_015_2	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	015	2	1	04	01	H5216_015_2	2	3		01	11a;11b;11c;12;		2		1	20	20	2			2	
H5216	015	2	1	04	01	H5216_015_2	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	015	2	1	04	01	H5216_015_2	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;15;16b;17a;18a;	14b;	2		1	35	35	2			2	
H5216	015	2	1	04	01	H5216_015_2	2	6		01	14a;		2		1	35	35	1	0.00	0.00	2	
H5216	015	2	1	04	01	H5216_015_2	2	7		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	015	2	1	04	01	H5216_015_2	2	8		10		13b;	1	30.00	1	50	50	2			2	
H5216	017	0	1	04	01	H5216_017_0	2	1		11	9d;17b;	9d;	2		2			1	0.00	0.00	2	
H5216	017	0	1	04	01	H5216_017_0	2	2		01	11a;11b;11c;12;		2		1	20	20	2			2	
H5216	017	0	1	04	01	H5216_017_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	017	0	1	04	01	H5216_017_0	2	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;15;16b;17a;18a;	14b;14c;	2		1	50	50	2			2	
H5216	017	0	1	04	01	H5216_017_0	2	5		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	018	0	1	04	01	H5216_018_0	2	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	018	0	1	04	01	H5216_018_0	2	10		10		16b;	2		1	50	80	2			2	
H5216	018	0	1	04	01	H5216_018_0	2	2		10		18b;	2		2			1	499.00	799.00	2	
H5216	018	0	1	04	01	H5216_018_0	2	3		01	11a;12;		2		1	20	20	2			2	
H5216	018	0	1	04	01	H5216_018_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	018	0	1	04	01	H5216_018_0	2	5		01	15;		2		1	20	30	2			2	
H5216	018	0	1	04	01	H5216_018_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	018	0	1	04	01	H5216_018_0	2	7		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	018	0	1	04	01	H5216_018_0	2	8		10		13c;14c;16a;	2		1	50	50	2			2	
H5216	018	0	1	04	01	H5216_018_0	2	9		10		13b;	1	45.00	1	50	50	2			2	
H5216	019	0	1	04	01	H5216_019_0	2	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	019	0	1	04	01	H5216_019_0	2	2		10		18b;	2		2			1	499.00	799.00	2	
H5216	019	0	1	04	01	H5216_019_0	2	3		01	11a;12;		2		1	20	20	2			2	
H5216	019	0	1	04	01	H5216_019_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	019	0	1	04	01	H5216_019_0	2	5		01	15;		2		1	20	30	2			2	
H5216	019	0	1	04	01	H5216_019_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	019	0	1	04	01	H5216_019_0	2	7		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	019	0	1	04	01	H5216_019_0	2	8		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	019	0	1	04	01	H5216_019_0	2	9		10		13b;	1	45.00	1	50	50	2			2	
H5216	020	0	1	04	01	H5216_020_0	2	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	020	0	1	04	01	H5216_020_0	2	2		10		18b;	2		2			1	499.00	799.00	2	
H5216	020	0	1	04	01	H5216_020_0	2	3		01	6;11a;11b;11c;12;		2		1	20	20	2			2	
H5216	020	0	1	04	01	H5216_020_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	020	0	1	04	01	H5216_020_0	2	5		01	8a1;15;		2		1	20	30	2			2	
H5216	020	0	1	04	01	H5216_020_0	2	6		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	020	0	1	04	01	H5216_020_0	2	7		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	020	0	1	04	01	H5216_020_0	2	8		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	020	0	1	04	01	H5216_020_0	2	9		10		13b;	1	45.00	1	50	50	2			2	
H5216	021	0	1	04	01	H5216_021_0	2	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	021	0	1	04	01	H5216_021_0	2	2		10		18b;	2		2			1	499.00	799.00	2	
H5216	021	0	1	04	01	H5216_021_0	2	3		01	12;		2		1	20	20	2			2	
H5216	021	0	1	04	01	H5216_021_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	021	0	1	04	01	H5216_021_0	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	021	0	1	04	01	H5216_021_0	2	6		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	021	0	1	04	01	H5216_021_0	2	7		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	021	0	1	04	01	H5216_021_0	2	8		10		13b;	1	45.00	1	50	50	2			2	
H5216	022	0	1	04	01	H5216_022_0	2	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	022	0	1	04	01	H5216_022_0	2	2		10		18b;	2		2			1	499.00	799.00	2	
H5216	022	0	1	04	01	H5216_022_0	2	3		01	12;		2		1	20	20	2			2	
H5216	022	0	1	04	01	H5216_022_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	022	0	1	04	01	H5216_022_0	2	5		01	15;		2		1	20	30	2			2	
H5216	022	0	1	04	01	H5216_022_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	022	0	1	04	01	H5216_022_0	2	7		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	022	0	1	04	01	H5216_022_0	2	8		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	022	0	1	04	01	H5216_022_0	2	9		10		13b;	1	45.00	1	50	50	2			2	
H5216	023	0	1	04	01	H5216_023_0	4	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	023	0	1	04	01	H5216_023_0	4	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	023	0	1	04	01	H5216_023_0	4	3		01	11a;12;		2		1	20	20	2			2	
H5216	023	0	1	04	01	H5216_023_0	4	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	023	0	1	04	01	H5216_023_0	4	5		01	15;		2		1	20	50	2			2	
H5216	023	0	1	04	01	H5216_023_0	4	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13c;14b;14c;16a;16b;	2		1	50	50	2			2	
H5216	023	0	1	04	01	H5216_023_0	4	7		10		13b;	1	30.00	1	50	50	2			2	
H5216	023	0	1	04	01	H5216_023_0	4	8		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	024	0	1	04	01	H5216_024_0	3	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5216	024	0	1	04	01	H5216_024_0	3	2		01	6;11a;11b;11c;12;		2		1	20	20	2			2	
H5216	024	0	1	04	01	H5216_024_0	3	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	024	0	1	04	01	H5216_024_0	3	4		01	8a1;15;		2		1	20	30	2			2	
H5216	024	0	1	04	01	H5216_024_0	3	5		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	024	0	1	04	01	H5216_024_0	3	6		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	024	0	1	04	01	H5216_024_0	3	7		10		13c;14c;	2		1	50	50	2			2	
H5216	024	0	1	04	01	H5216_024_0	3	8		10		13b;	1	30.00	1	50	50	2			2	
H5216	025	0	1	04	01	H5216_025_0	2	1		11	9d;17b;	9d;	2		2			1	0.00	0.00	2	
H5216	025	0	1	04	01	H5216_025_0	2	2		01	11a;12;		2		1	20	20	2			2	
H5216	025	0	1	04	01	H5216_025_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	025	0	1	04	01	H5216_025_0	2	4		01	15;		2		1	20	35	2			2	
H5216	025	0	1	04	01	H5216_025_0	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	14b;	2		1	35	35	2			2	
H5216	025	0	1	04	01	H5216_025_0	2	6		01	14a;		2		1	35	35	1	0.00	0.00	2	
H5216	025	0	1	04	01	H5216_025_0	2	7		10		13c;14c;	2		1	50	50	2			2	
H5216	025	0	1	04	01	H5216_025_0	2	8		10		13b;	1	30.00	1	50	50	2			2	
H5216	026	0	1	04	01	H5216_026_0	2	1		11	9d;17b;	9d;	2		2			1	0.00	0.00	2	
H5216	026	0	1	04	01	H5216_026_0	2	2		01	11a;12;		2		1	20	20	2			2	
H5216	026	0	1	04	01	H5216_026_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	026	0	1	04	01	H5216_026_0	2	4		01	15;		2		1	20	40	2			2	
H5216	026	0	1	04	01	H5216_026_0	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	14b;	2		1	40	40	2			2	
H5216	026	0	1	04	01	H5216_026_0	2	6		01	14a;		2		1	40	40	1	0.00	0.00	2	
H5216	026	0	1	04	01	H5216_026_0	2	7		10		13c;14c;	2		1	50	50	2			2	
H5216	026	0	1	04	01	H5216_026_0	2	8		10		13b;	1	30.00	1	50	50	2			2	
H5216	027	0	1	04	01	H5216_027_0	2	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5216	027	0	1	04	01	H5216_027_0	2	10		10		13b;	1	30.00	1	50	50	2			2	
H5216	027	0	1	04	01	H5216_027_0	2	2		01	11a;12;		2		1	20	20	2			2	
H5216	027	0	1	04	01	H5216_027_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	027	0	1	04	01	H5216_027_0	2	4		01	15;		2		1	20	35	2			2	
H5216	027	0	1	04	01	H5216_027_0	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	14b;	2		1	35	35	2			2	
H5216	027	0	1	04	01	H5216_027_0	2	6		01	14a;		2		1	35	35	1	0.00	0.00	2	
H5216	027	0	1	04	01	H5216_027_0	2	7		01	11c;		2		1	35	40	2			2	
H5216	027	0	1	04	01	H5216_027_0	2	8		01	11b;		2		1	40	40	2			2	
H5216	027	0	1	04	01	H5216_027_0	2	9		10		13c;14c;	2		1	50	50	2			2	
H5216	028	0	1	04	01	H5216_028_0	2	1		11	9d;17b;	9d;	2		2			1	0.00	0.00	2	
H5216	028	0	1	04	01	H5216_028_0	2	2		01	12;		2		1	20	20	2			2	
H5216	028	0	1	04	01	H5216_028_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	028	0	1	04	01	H5216_028_0	2	4		01	15;		2		1	20	35	2			2	
H5216	028	0	1	04	01	H5216_028_0	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;16b;17a;18a;	14b;	2		1	35	35	2			2	
H5216	028	0	1	04	01	H5216_028_0	2	6		01	14a;		2		1	35	35	1	0.00	0.00	2	
H5216	028	0	1	04	01	H5216_028_0	2	7		10		13c;14c;	2		1	50	50	2			2	
H5216	028	0	1	04	01	H5216_028_0	2	8		10		13b;	1	30.00	1	50	50	2			2	
H5216	029	0	1	04	01	H5216_029_0	2	1		11	9d;17b;	9d;	2		2			1	0.00	0.00	2	
H5216	029	0	1	04	01	H5216_029_0	2	2		01	12;		2		1	20	20	2			2	
H5216	029	0	1	04	01	H5216_029_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	029	0	1	04	01	H5216_029_0	2	4		01	15;		2		1	20	35	2			2	
H5216	029	0	1	04	01	H5216_029_0	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;16b;17a;18a;	14b;	2		1	35	35	2			2	
H5216	029	0	1	04	01	H5216_029_0	2	6		01	14a;		2		1	35	35	1	0.00	0.00	2	
H5216	029	0	1	04	01	H5216_029_0	2	7		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	029	0	1	04	01	H5216_029_0	2	8		10		13b;	1	30.00	1	50	50	2			2	
H5216	030	1	1	04	01	H5216_030_1	2	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5216	030	1	1	04	01	H5216_030_1	2	10		10		13b;	1	30.00	1	50	50	2			2	
H5216	030	1	1	04	01	H5216_030_1	2	2		01	11a;12;		2		1	20	20	2			2	
H5216	030	1	1	04	01	H5216_030_1	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	030	1	1	04	01	H5216_030_1	2	4		01	15;		2		1	20	35	2			2	
H5216	030	1	1	04	01	H5216_030_1	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	14b;	2		1	35	35	2			2	
H5216	030	1	1	04	01	H5216_030_1	2	6		01	14a;		2		1	35	35	1	0.00	0.00	2	
H5216	030	1	1	04	01	H5216_030_1	2	7		01	11c;		2		1	35	40	2			2	
H5216	030	1	1	04	01	H5216_030_1	2	8		01	11b;		2		1	40	40	2			2	
H5216	030	1	1	04	01	H5216_030_1	2	9		10		13c;14c;	2		1	50	50	2			2	
H5216	030	2	1	04	01	H5216_030_2	2	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5216	030	2	1	04	01	H5216_030_2	2	10		10		13b;	1	30.00	1	50	50	2			2	
H5216	030	2	1	04	01	H5216_030_2	2	2		01	11a;12;		2		1	20	20	2			2	
H5216	030	2	1	04	01	H5216_030_2	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	030	2	1	04	01	H5216_030_2	2	4		01	15;		2		1	20	35	2			2	
H5216	030	2	1	04	01	H5216_030_2	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	14b;	2		1	35	35	2			2	
H5216	030	2	1	04	01	H5216_030_2	2	6		01	14a;		2		1	35	35	1	0.00	0.00	2	
H5216	030	2	1	04	01	H5216_030_2	2	7		01	11c;		2		1	35	40	2			2	
H5216	030	2	1	04	01	H5216_030_2	2	8		01	11b;		2		1	40	40	2			2	
H5216	030	2	1	04	01	H5216_030_2	2	9		10		13c;14c;	2		1	50	50	2			2	
H5216	031	1	1	04	01	H5216_031_1	2	1		11	9d;17b;	9d;	2		2			1	0.00	0.00	2	
H5216	031	1	1	04	01	H5216_031_1	2	2		01	11a;12;		2		1	20	20	2			2	
H5216	031	1	1	04	01	H5216_031_1	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	031	1	1	04	01	H5216_031_1	2	4		01	15;		2		1	20	35	2			2	
H5216	031	1	1	04	01	H5216_031_1	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;16b;17a;18a;	14b;	2		1	35	35	2			2	
H5216	031	1	1	04	01	H5216_031_1	2	6		01	14a;		2		1	35	35	1	0.00	0.00	2	
H5216	031	1	1	04	01	H5216_031_1	2	7		01	11c;		2		1	35	40	2			2	
H5216	031	1	1	04	01	H5216_031_1	2	8		10		13c;14c;	2		1	50	50	2			2	
H5216	031	1	1	04	01	H5216_031_1	2	9		10		13b;	1	30.00	1	50	50	2			2	
H5216	031	2	1	04	01	H5216_031_2	2	1		11	9d;17b;	9d;	2		2			1	0.00	0.00	2	
H5216	031	2	1	04	01	H5216_031_2	2	2		01	11a;12;		2		1	20	20	2			2	
H5216	031	2	1	04	01	H5216_031_2	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	031	2	1	04	01	H5216_031_2	2	4		01	15;		2		1	20	35	2			2	
H5216	031	2	1	04	01	H5216_031_2	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;16b;17a;18a;	14b;	2		1	35	35	2			2	
H5216	031	2	1	04	01	H5216_031_2	2	6		01	14a;		2		1	35	35	1	0.00	0.00	2	
H5216	031	2	1	04	01	H5216_031_2	2	7		01	11c;		2		1	35	40	2			2	
H5216	031	2	1	04	01	H5216_031_2	2	8		10		13c;14c;	2		1	50	50	2			2	
H5216	031	2	1	04	01	H5216_031_2	2	9		10		13b;	1	30.00	1	50	50	2			2	
H5216	032	0	1	04	01	H5216_032_0	4	1		11	9d;	9d;17a;18a;	2		2			1	0.00	0.00	2	
H5216	032	0	1	04	01	H5216_032_0	4	10		10		13b;	1	25.00	1	50	50	2			2	
H5216	032	0	1	04	01	H5216_032_0	4	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	032	0	1	04	01	H5216_032_0	4	3		01	12;		2		1	20	20	2			2	
H5216	032	0	1	04	01	H5216_032_0	4	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	032	0	1	04	01	H5216_032_0	4	5		01	15;		2		1	20	40	2			2	
H5216	032	0	1	04	01	H5216_032_0	4	6		01	11a;		2		1	25	25	2			2	
H5216	032	0	1	04	01	H5216_032_0	4	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;17b;18a;	14b;	2		1	40	40	2			2	
H5216	032	0	1	04	01	H5216_032_0	4	8		01	14a;		2		1	40	40	1	0.00	0.00	2	
H5216	032	0	1	04	01	H5216_032_0	4	9		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	033	1	1	04	01	H5216_033_1	3	1		11	9d;	9d;17a;	2		2			1	0.00	0.00	2	
H5216	033	1	1	04	01	H5216_033_1	3	2		01	12;		2		1	20	20	2			2	
H5216	033	1	1	04	01	H5216_033_1	3	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	033	1	1	04	01	H5216_033_1	3	4		01	15;		2		1	20	50	2			2	
H5216	033	1	1	04	01	H5216_033_1	3	5		01	11a;		2		1	24	24	2			2	
H5216	033	1	1	04	01	H5216_033_1	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;17b;18a;	13c;14b;14c;	2		1	50	50	2			2	
H5216	033	1	1	04	01	H5216_033_1	3	7		10		13b;	1	25.00	1	50	50	2			2	
H5216	033	1	1	04	01	H5216_033_1	3	8		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	033	2	1	04	01	H5216_033_2	3	1		11	9d;	9d;17a;	2		2			1	0.00	0.00	2	
H5216	033	2	1	04	01	H5216_033_2	3	2		01	12;		2		1	20	20	2			2	
H5216	033	2	1	04	01	H5216_033_2	3	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	033	2	1	04	01	H5216_033_2	3	4		01	15;		2		1	20	50	2			2	
H5216	033	2	1	04	01	H5216_033_2	3	5		01	11a;		2		1	24	24	2			2	
H5216	033	2	1	04	01	H5216_033_2	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;17b;18a;	13c;14b;14c;	2		1	50	50	2			2	
H5216	033	2	1	04	01	H5216_033_2	3	7		10		13b;	1	25.00	1	50	50	2			2	
H5216	033	2	1	04	01	H5216_033_2	3	8		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	034	0	1	04	01	H5216_034_0	2	1		11	9d;	9d;17a;18a;	2		2			1	0.00	0.00	2	
H5216	034	0	1	04	01	H5216_034_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	034	0	1	04	01	H5216_034_0	2	3		01	12;		2		1	20	20	2			2	
H5216	034	0	1	04	01	H5216_034_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	034	0	1	04	01	H5216_034_0	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;16b;17a;17b;18a;	14b;	2		1	40	40	2			2	
H5216	034	0	1	04	01	H5216_034_0	2	6		01	14a;		2		1	40	40	1	0.00	0.00	2	
H5216	034	0	1	04	01	H5216_034_0	2	7		11	15;	13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	034	0	1	04	01	H5216_034_0	2	8		10		13b;	1	50.00	1	50	50	2			2	
H5216	035	0	1	04	01	H5216_035_0	3	1		11	9d;	9d;17a;18a;	2		2			1	0.00	0.00	2	
H5216	035	0	1	04	01	H5216_035_0	3	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	035	0	1	04	01	H5216_035_0	3	3		01	12;		2		1	20	20	2			2	
H5216	035	0	1	04	01	H5216_035_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	035	0	1	04	01	H5216_035_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;16b;17a;17b;18a;	14b;	2		1	40	40	2			2	
H5216	035	0	1	04	01	H5216_035_0	3	6		01	14a;		2		1	40	40	1	0.00	0.00	2	
H5216	035	0	1	04	01	H5216_035_0	3	7		11	15;	13c;14c;16a;	2		1	50	50	2			2	
H5216	035	0	1	04	01	H5216_035_0	3	8		10		13b;	1	50.00	1	50	50	2			2	
H5216	035	0	1	04	01	H5216_035_0	3	9		10		16b;	2		1	50	55	2			2	
H5216	036	0	1	04	01	H5216_036_0	3	1		11	9d;17b;	9d;17a;18a;	2		2			1	0.00	0.00	2	
H5216	036	0	1	04	01	H5216_036_0	3	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	036	0	1	04	01	H5216_036_0	3	3		01	12;		2		1	20	20	2			2	
H5216	036	0	1	04	01	H5216_036_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	036	0	1	04	01	H5216_036_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	036	0	1	04	01	H5216_036_0	3	6		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	036	0	1	04	01	H5216_036_0	3	7		10		13c;14c;16a;	2		1	50	50	2			2	
H5216	036	0	1	04	01	H5216_036_0	3	8		10		13b;	1	50.00	1	50	50	2			2	
H5216	036	0	1	04	01	H5216_036_0	3	9		10		16b;	2		1	50	55	2			2	
H5216	037	0	1	04	01	H5216_037_0	2	1		11	9d;17b;	9d;17a;18a;	2		2			1	0.00	0.00	2	
H5216	037	0	1	04	01	H5216_037_0	2	10		10		13b;	1	50.00	1	50	50	2			2	
H5216	037	0	1	04	01	H5216_037_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	037	0	1	04	01	H5216_037_0	2	3		01	12;		2		1	20	20	2			2	
H5216	037	0	1	04	01	H5216_037_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	037	0	1	04	01	H5216_037_0	2	5		01	11a;		2		1	25	25	2			2	
H5216	037	0	1	04	01	H5216_037_0	2	6		01	11b;		2		1	30	30	2			2	
H5216	037	0	1	04	01	H5216_037_0	2	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11c;14d;14e;15;16b;17a;18a;	14b;	2		1	40	40	2			2	
H5216	037	0	1	04	01	H5216_037_0	2	8		01	14a;		2		1	40	40	1	0.00	0.00	2	
H5216	037	0	1	04	01	H5216_037_0	2	9		10		13c;14c;	2		1	50	50	2			2	
H5216	038	0	1	04	01	H5216_038_0	2	1		11	9d;17b;	9d;17a;18a;	2		2			1	0.00	0.00	2	
H5216	038	0	1	04	01	H5216_038_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	038	0	1	04	01	H5216_038_0	2	3		01	12;		2		1	20	20	2			2	
H5216	038	0	1	04	01	H5216_038_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	038	0	1	04	01	H5216_038_0	2	5		01	11a;		2		1	30	30	2			2	
H5216	038	0	1	04	01	H5216_038_0	2	6		01	11b;11c;		2		1	40	40	2			2	
H5216	038	0	1	04	01	H5216_038_0	2	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;15;16b;17a;18a;	13c;14b;14c;	2		1	50	50	2			2	
H5216	038	0	1	04	01	H5216_038_0	2	8		10		13b;	1	50.00	1	50	50	2			2	
H5216	038	0	1	04	01	H5216_038_0	2	9		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	039	0	1	04	01	H5216_039_0	2	1		11	9d;17b;	9d;17a;18a;	2		2			1	0.00	0.00	2	
H5216	039	0	1	04	01	H5216_039_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	039	0	1	04	01	H5216_039_0	2	3		01	12;		2		1	20	20	2			2	
H5216	039	0	1	04	01	H5216_039_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	039	0	1	04	01	H5216_039_0	2	5		01	11a;		2		1	25	25	2			2	
H5216	039	0	1	04	01	H5216_039_0	2	6		01	11b;11c;		2		1	30	30	2			2	
H5216	039	0	1	04	01	H5216_039_0	2	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;15;16b;17a;18a;	13c;14b;14c;	2		1	50	50	2			2	
H5216	039	0	1	04	01	H5216_039_0	2	8		10		13b;	1	25.00	1	50	50	2			2	
H5216	039	0	1	04	01	H5216_039_0	2	9		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	040	0	1	04	01	H5216_040_0	4	1		11	9d;	9d;17a;	2		2			1	0.00	0.00	2	
H5216	040	0	1	04	01	H5216_040_0	4	2		01	12;		2		1	20	20	2			2	
H5216	040	0	1	04	01	H5216_040_0	4	3		01	10a;		2		1	20	20	1	250.00	250.00	2	
H5216	040	0	1	04	01	H5216_040_0	4	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;15;16b;17a;17b;18a;	14b;	2		1	40	40	2			2	
H5216	040	0	1	04	01	H5216_040_0	4	5		01	14a;		2		1	40	40	1	0.00	0.00	2	
H5216	040	0	1	04	01	H5216_040_0	4	6		10		13a;13c;14c;16a;	2		1	50	50	2			2	
H5216	040	0	1	04	01	H5216_040_0	4	7		10		13b;	1	50.00	1	50	50	2			2	
H5216	041	0	1	04	01	H5216_041_0	2	1		11	9d;	9d;17a;	2		2			1	0.00	0.00	2	
H5216	041	0	1	04	01	H5216_041_0	2	10		10		13b;	1	40.00	1	50	50	2			2	
H5216	041	0	1	04	01	H5216_041_0	2	2		11	7f;	7f;	2		2			1	65.00	65.00	2	
H5216	041	0	1	04	01	H5216_041_0	2	3		01	12;		2		1	20	20	2			2	
H5216	041	0	1	04	01	H5216_041_0	2	4		01	10a;		2		1	20	20	1	250.00	250.00	2	
H5216	041	0	1	04	01	H5216_041_0	2	5		10		18a;18b;	2		1	25	25	2			2	
H5216	041	0	1	04	01	H5216_041_0	2	6		01	11a;		2		1	30	30	2			2	
H5216	041	0	1	04	01	H5216_041_0	2	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	14b;	2		1	40	40	2			2	
H5216	041	0	1	04	01	H5216_041_0	2	8		01	14a;		2		1	40	40	1	0.00	0.00	2	
H5216	041	0	1	04	01	H5216_041_0	2	9		10		13a;13c;14c;	2		1	50	50	2			2	
H5216	042	0	1	04	01	H5216_042_0	3	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5216	042	0	1	04	01	H5216_042_0	3	2		01	12;		2		1	20	20	2			2	
H5216	042	0	1	04	01	H5216_042_0	3	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	042	0	1	04	01	H5216_042_0	3	4		01	15;		2		1	20	40	2			2	
H5216	042	0	1	04	01	H5216_042_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;16b;17a;18a;	14b;	2		1	40	40	2			2	
H5216	042	0	1	04	01	H5216_042_0	3	6		01	14a;		2		1	40	50	1	0.00	0.00	2	
H5216	042	0	1	04	01	H5216_042_0	3	7		10		13c;14c;16a;	2		1	50	50	2			2	
H5216	042	0	1	04	01	H5216_042_0	3	8		10		13b;	1	25.00	1	50	50	2			2	
H5216	043	1	1	04	01	H5216_043_1	2	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5216	043	1	1	04	01	H5216_043_1	2	10		10		16b;	2		1	50	55	2			2	
H5216	043	1	1	04	01	H5216_043_1	2	2		01	11a;12;		2		1	20	20	2			2	
H5216	043	1	1	04	01	H5216_043_1	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	043	1	1	04	01	H5216_043_1	2	4		01	15;		2		1	20	40	2			2	
H5216	043	1	1	04	01	H5216_043_1	2	5		01	11b;11c;		2		1	25	25	2			2	
H5216	043	1	1	04	01	H5216_043_1	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	14b;	2		1	40	40	2			2	
H5216	043	1	1	04	01	H5216_043_1	2	7		01	14a;		2		1	40	50	1	0.00	0.00	2	
H5216	043	1	1	04	01	H5216_043_1	2	8		10		13c;14c;16a;	2		1	50	50	2			2	
H5216	043	1	1	04	01	H5216_043_1	2	9		10		13b;	1	50.00	1	50	50	2			2	
H5216	043	2	1	04	01	H5216_043_2	2	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5216	043	2	1	04	01	H5216_043_2	2	10		10		16b;	2		1	50	55	2			2	
H5216	043	2	1	04	01	H5216_043_2	2	2		01	11a;12;		2		1	20	20	2			2	
H5216	043	2	1	04	01	H5216_043_2	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	043	2	1	04	01	H5216_043_2	2	4		01	15;		2		1	20	40	2			2	
H5216	043	2	1	04	01	H5216_043_2	2	5		01	11b;11c;		2		1	25	25	2			2	
H5216	043	2	1	04	01	H5216_043_2	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	14b;	2		1	40	40	2			2	
H5216	043	2	1	04	01	H5216_043_2	2	7		01	14a;		2		1	40	50	1	0.00	0.00	2	
H5216	043	2	1	04	01	H5216_043_2	2	8		10		13c;14c;16a;	2		1	50	50	2			2	
H5216	043	2	1	04	01	H5216_043_2	2	9		10		13b;	1	50.00	1	50	50	2			2	
H5216	044	0	1	04	01	H5216_044_0	4	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	044	0	1	04	01	H5216_044_0	4	2		10		18b;	2		2			1	499.00	799.00	2	
H5216	044	0	1	04	01	H5216_044_0	4	3		11	7a;12;	14b;	2		1	20	20	2			2	
H5216	044	0	1	04	01	H5216_044_0	4	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	044	0	1	04	01	H5216_044_0	4	5		01	8a1;8a2;8b1;8b3;14d;14e;15;		2		1	20	35	2			2	
H5216	044	0	1	04	01	H5216_044_0	4	6		01	14a;		2		1	20	35	1	0.00	0.00	2	
H5216	044	0	1	04	01	H5216_044_0	4	7		01	3-1;3-2;3-3;5;6;7b;7c;7d;7e;7f;7g;7h;7i;8b2;9a;9b;9c;11a;11b;11c;16b;17a;18a;		2		1	35	35	2			2	
H5216	044	0	1	04	01	H5216_044_0	4	8		10		13a;13c;14c;	2		1	50	50	2			2	
H5216	044	0	1	04	01	H5216_044_0	4	9		10		13b;	1	30.00	1	50	50	2			2	
H5216	045	0	1	04	01	H5216_045_0	3	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	045	0	1	04	01	H5216_045_0	3	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	045	0	1	04	01	H5216_045_0	3	3		01	6;11a;11b;11c;12;		2		1	20	20	2			2	
H5216	045	0	1	04	01	H5216_045_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	045	0	1	04	01	H5216_045_0	3	5		01	8a1;15;		2		1	20	50	2			2	
H5216	045	0	1	04	01	H5216_045_0	3	6		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	13c;14b;14c;16a;16b;	2		1	50	50	2			2	
H5216	045	0	1	04	01	H5216_045_0	3	7		10		13b;	1	30.00	1	50	50	2			2	
H5216	045	0	1	04	01	H5216_045_0	3	8		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	046	0	1	04	01	H5216_046_0	3	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	046	0	1	04	01	H5216_046_0	3	2		10		18b;	2		2			1	399.00	699.00	2	
H5216	046	0	1	04	01	H5216_046_0	3	3		10		16a;	2		1	0	0	2			2	
H5216	046	0	1	04	01	H5216_046_0	3	4		01	12;		2		1	20	20	2			2	
H5216	046	0	1	04	01	H5216_046_0	3	5		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	046	0	1	04	01	H5216_046_0	3	6		01	11a;		2		1	25	25	2			2	
H5216	046	0	1	04	01	H5216_046_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13a;13c;14b;14c;16b;	2		1	50	50	2			2	
H5216	046	0	1	04	01	H5216_046_0	3	8		10		13b;	1	15.00	1	50	50	2			2	
H5216	046	0	1	04	01	H5216_046_0	3	9		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	047	0	1	04	01	H5216_047_0	4	1		11	9d;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	047	0	1	04	01	H5216_047_0	4	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	047	0	1	04	01	H5216_047_0	4	3		01	12;		2		1	20	20	2			2	
H5216	047	0	1	04	01	H5216_047_0	4	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	047	0	1	04	01	H5216_047_0	4	5		01	11a;		2		1	28	28	2			2	
H5216	047	0	1	04	01	H5216_047_0	4	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;14b;14c;	2		1	50	50	2			2	
H5216	047	0	1	04	01	H5216_047_0	4	7		10		13b;	1	30.00	1	50	50	2			2	
H5216	047	0	1	04	01	H5216_047_0	4	8		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	048	0	1	04	01	H5216_048_0	4	1		11	9d;	9d;17a;	2		2			1	0.00	0.00	2	
H5216	048	0	1	04	01	H5216_048_0	4	2		01	12;15;		2		1	20	20	2			2	
H5216	048	0	1	04	01	H5216_048_0	4	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	048	0	1	04	01	H5216_048_0	4	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;16b;17a;17b;18a;	14b;	2		1	30	30	2			2	
H5216	048	0	1	04	01	H5216_048_0	4	5		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	048	0	1	04	01	H5216_048_0	4	6		10		13c;14c;16a;	2		1	50	50	2			2	
H5216	048	0	1	04	01	H5216_048_0	4	7		10		13b;	1	30.00	1	50	50	2			2	
H5216	048	0	1	04	01	H5216_048_0	4	8		10		16b;	2		1	50	55	2			2	
H5216	050	0	1	04	01	H5216_050_0	3	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	050	0	1	04	01	H5216_050_0	3	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	050	0	1	04	01	H5216_050_0	3	3		01	11a;12;		2		1	20	20	2			2	
H5216	050	0	1	04	01	H5216_050_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	050	0	1	04	01	H5216_050_0	3	5		01	15;		2		1	20	50	2			2	
H5216	050	0	1	04	01	H5216_050_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13c;14b;14c;16a;16b;	2		1	50	50	2			2	
H5216	050	0	1	04	01	H5216_050_0	3	7		10		13b;	1	30.00	1	50	50	2			2	
H5216	050	0	1	04	01	H5216_050_0	3	8		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	051	0	1	04	01	H5216_051_0	3	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	051	0	1	04	01	H5216_051_0	3	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	051	0	1	04	01	H5216_051_0	3	3		01	11a;12;		2		1	20	20	2			2	
H5216	051	0	1	04	01	H5216_051_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	051	0	1	04	01	H5216_051_0	3	5		01	15;		2		1	20	50	2			2	
H5216	051	0	1	04	01	H5216_051_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13c;14b;14c;16a;16b;	2		1	50	50	2			2	
H5216	051	0	1	04	01	H5216_051_0	3	7		10		13b;	1	30.00	1	50	50	2			2	
H5216	051	0	1	04	01	H5216_051_0	3	8		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	052	1	1	04	01	H5216_052_1	3	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5216	052	1	1	04	01	H5216_052_1	3	2		01	6;11a;11b;12;		2		1	20	20	2			2	
H5216	052	1	1	04	01	H5216_052_1	3	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	052	1	1	04	01	H5216_052_1	3	4		01	8a1;15;		2		1	20	50	2			2	
H5216	052	1	1	04	01	H5216_052_1	3	5		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;8b1;8b2;8b3;9a;9b;9c;11c;14d;14e;16b;17a;18a;	13c;14b;14c;16a;16b;	2		1	50	50	2			2	
H5216	052	1	1	04	01	H5216_052_1	3	6		10		13b;	1	30.00	1	50	50	2			2	
H5216	052	1	1	04	01	H5216_052_1	3	7		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	052	2	1	04	01	H5216_052_2	3	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5216	052	2	1	04	01	H5216_052_2	3	2		01	6;11a;11b;12;		2		1	20	20	2			2	
H5216	052	2	1	04	01	H5216_052_2	3	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	052	2	1	04	01	H5216_052_2	3	4		01	8a1;15;		2		1	20	30	2			2	
H5216	052	2	1	04	01	H5216_052_2	3	5		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;8b1;8b2;8b3;9a;9b;9c;11c;14d;14e;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	052	2	1	04	01	H5216_052_2	3	6		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	052	2	1	04	01	H5216_052_2	3	7		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	052	2	1	04	01	H5216_052_2	3	8		10		13b;	1	30.00	1	50	50	2			2	
H5216	053	0	1	04	01	H5216_053_0	3	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5216	053	0	1	04	01	H5216_053_0	3	2		01	11a;12;		2		1	20	20	2			2	
H5216	053	0	1	04	01	H5216_053_0	3	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	053	0	1	04	01	H5216_053_0	3	4		01	15;		2		1	20	50	2			2	
H5216	053	0	1	04	01	H5216_053_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13c;14b;14c;16a;16b;	2		1	50	50	2			2	
H5216	053	0	1	04	01	H5216_053_0	3	6		10		13b;	1	30.00	1	50	50	2			2	
H5216	053	0	1	04	01	H5216_053_0	3	7		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	054	0	1	04	01	H5216_054_0	2	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H5216	054	0	1	04	01	H5216_054_0	2	2		01	11a;12;		2		1	20	20	2			2	
H5216	054	0	1	04	01	H5216_054_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	054	0	1	04	01	H5216_054_0	2	4		01	15;		2		1	20	50	2			2	
H5216	054	0	1	04	01	H5216_054_0	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	14b;14c;16a;16b;	2		1	50	50	2			2	
H5216	054	0	1	04	01	H5216_054_0	2	6		10		13b;	1	30.00	1	50	50	2			2	
H5216	054	0	1	04	01	H5216_054_0	2	7		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	055	0	1	04	01	H5216_055_0	3	1		11	9d;17b;	9d;17a;18a;	2		2			1	0.00	0.00	2	
H5216	055	0	1	04	01	H5216_055_0	3	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	055	0	1	04	01	H5216_055_0	3	3		01	11a;12;		2		1	20	20	2			2	
H5216	055	0	1	04	01	H5216_055_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	055	0	1	04	01	H5216_055_0	3	5		01	15;		2		1	20	50	2			2	
H5216	055	0	1	04	01	H5216_055_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14a;14d;14e;16b;17a;18a;	13c;14b;14c;16a;16b;	2		1	50	50	2			2	
H5216	055	0	1	04	01	H5216_055_0	3	7		10		13b;	1	30.00	1	50	50	2			2	
H5216	056	0	1	04	01	H5216_056_0	2	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	056	0	1	04	01	H5216_056_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	056	0	1	04	01	H5216_056_0	2	3		01	12;		2		1	20	20	2			2	
H5216	056	0	1	04	01	H5216_056_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	056	0	1	04	01	H5216_056_0	2	5		01	11a;11b;11c;		2		1	25	25	2			2	
H5216	056	0	1	04	01	H5216_056_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	056	0	1	04	01	H5216_056_0	2	7		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	056	0	1	04	01	H5216_056_0	2	8		10		13c;14c;	2		1	50	50	2			2	
H5216	056	0	1	04	01	H5216_056_0	2	9		10		13b;	1	25.00	1	50	50	2			2	
H5216	057	0	1	04	01	H5216_057_0	3	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5216	057	0	1	04	01	H5216_057_0	3	10		01	8a1;8a2;8b1;8b3;14e;		2		1	30	30	1	20.00	60.00	2	
H5216	057	0	1	04	01	H5216_057_0	3	11		01	3-1;3-2;3-3;7c;7i;9c;		2		1	30	30	1	60.00	60.00	2	
H5216	057	0	1	04	01	H5216_057_0	3	12		10		13c;14c;	2		1	50	50	2			2	
H5216	057	0	1	04	01	H5216_057_0	3	13		10		13b;	1	50.00	1	50	50	2			2	
H5216	057	0	1	04	01	H5216_057_0	3	2		11	7a;	14b;	2		2			1	20.00	20.00	2	
H5216	057	0	1	04	01	H5216_057_0	3	3		01	14d;		2		2			1	20.00	60.00	2	
H5216	057	0	1	04	01	H5216_057_0	3	4		01	7b;7d;7e;7f;7g;7h;16b;17a;18a;		2		2			1	60.00	60.00	2	
H5216	057	0	1	04	01	H5216_057_0	3	5		01	8b2;12;		2		1	20	20	2			2	
H5216	057	0	1	04	01	H5216_057_0	3	6		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	057	0	1	04	01	H5216_057_0	3	7		01	11c;		2		1	20	30	2			2	
H5216	057	0	1	04	01	H5216_057_0	3	8		01	5;6;9a;9b;11a;11b;15;		2		1	30	30	2			2	
H5216	057	0	1	04	01	H5216_057_0	3	9		01	14a;		2		1	30	30	1	0.00	60.00	2	
H5216	058	0	1	04	01	H5216_058_0	3	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5216	058	0	1	04	01	H5216_058_0	3	10		01	8a1;8a2;8b1;8b3;14e;		2		1	30	30	1	20.00	65.00	2	
H5216	058	0	1	04	01	H5216_058_0	3	11		01	3-1;3-2;3-3;7c;7i;9c;		2		1	30	30	1	65.00	65.00	2	
H5216	058	0	1	04	01	H5216_058_0	3	12		10		13c;14c;	2		1	50	50	2			2	
H5216	058	0	1	04	01	H5216_058_0	3	2		11	7a;	14b;	2		2			1	20.00	20.00	2	
H5216	058	0	1	04	01	H5216_058_0	3	3		01	14d;		2		2			1	20.00	65.00	2	
H5216	058	0	1	04	01	H5216_058_0	3	4		01	7b;7d;7e;7f;7g;7h;16b;17a;18a;		2		2			1	65.00	65.00	2	
H5216	058	0	1	04	01	H5216_058_0	3	5		01	8b2;12;		2		1	20	20	2			2	
H5216	058	0	1	04	01	H5216_058_0	3	6		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	058	0	1	04	01	H5216_058_0	3	7		01	11c;		2		1	20	30	2			2	
H5216	058	0	1	04	01	H5216_058_0	3	8		01	5;6;9a;9b;11a;11b;15;		2		1	30	30	2			2	
H5216	058	0	1	04	01	H5216_058_0	3	9		01	14a;		2		1	30	30	1	0.00	65.00	2	
H5216	059	0	1	04	01	H5216_059_0	3	1		11	9d;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5216	059	0	1	04	01	H5216_059_0	3	2		01	11a;12;		2		1	20	20	2			2	
H5216	059	0	1	04	01	H5216_059_0	3	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	059	0	1	04	01	H5216_059_0	3	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	14b;	2		1	30	30	2			2	
H5216	059	0	1	04	01	H5216_059_0	3	5		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	059	0	1	04	01	H5216_059_0	3	6		10		13c;14c;	2		1	50	50	2			2	
H5216	059	0	1	04	01	H5216_059_0	3	7		10		13b;	1	45.00	1	50	50	2			2	
H5216	060	0	1	04	01	H5216_060_0	4	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5216	060	0	1	04	01	H5216_060_0	4	10		01	14a;		2		1	50	50	1	0.00	40.00	2	
H5216	060	0	1	04	01	H5216_060_0	4	11		01	3-1;3-2;3-3;7c;7i;8a2;8b1;8b2;8b3;9c;14e;		2		1	50	50	1	40.00	40.00	2	
H5216	060	0	1	04	01	H5216_060_0	4	2		11	7a;7b;7d;7e;7f;7g;7h;14d;16b;17a;18a;	14b;	2		2			1	40.00	40.00	2	
H5216	060	0	1	04	01	H5216_060_0	4	3		01	12;		2		1	20	20	2			2	
H5216	060	0	1	04	01	H5216_060_0	4	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	060	0	1	04	01	H5216_060_0	4	5		01	15;		2		1	20	50	2			2	
H5216	060	0	1	04	01	H5216_060_0	4	6		01	11a;		2		1	24	24	2			2	
H5216	060	0	1	04	01	H5216_060_0	4	7		01	8a1;		2		1	40	50	1	40.00	40.00	2	
H5216	060	0	1	04	01	H5216_060_0	4	8		11	5;6;9a;9b;11b;11c;	13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	060	0	1	04	01	H5216_060_0	4	9		10		13b;	1	10.00	1	50	50	2			2	
H5216	061	0	1	04	01	H5216_061_0	3	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H5216	061	0	1	04	01	H5216_061_0	3	10		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	061	0	1	04	01	H5216_061_0	3	11		01	3-1;3-2;3-3;7c;7i;8a1;8a2;8b1;8b2;8b3;9c;		2		1	50	50	1	65.00	65.00	2	
H5216	061	0	1	04	01	H5216_061_0	3	2		01	5;7a;7b;7d;7e;7f;7g;7h;16b;17a;18a;		2		2			1	65.00	65.00	2	
H5216	061	0	1	04	01	H5216_061_0	3	3		01	12;		2		1	20	20	2			2	
H5216	061	0	1	04	01	H5216_061_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	061	0	1	04	01	H5216_061_0	3	5		01	15;		2		1	20	50	2			2	
H5216	061	0	1	04	01	H5216_061_0	3	6		01	11b;		2		1	25	25	2			2	
H5216	061	0	1	04	01	H5216_061_0	3	7		01	11a;		2		1	30	30	2			2	
H5216	061	0	1	04	01	H5216_061_0	3	8		11	6;9a;9b;11c;14d;14e;	14b;14c;16a;16b;	2		1	50	50	2			2	
H5216	061	0	1	04	01	H5216_061_0	3	9		10		13b;	1	30.00	1	50	50	2			2	
H5216	062	0	1	04	01	H5216_062_0	3	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H5216	062	0	1	04	01	H5216_062_0	3	10		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	062	0	1	04	01	H5216_062_0	3	11		01	3-1;3-2;3-3;7c;7i;8a1;8a2;8b1;8b2;8b3;9c;		2		1	50	50	1	65.00	65.00	2	
H5216	062	0	1	04	01	H5216_062_0	3	2		01	5;7a;7b;7d;7e;7f;7g;7h;16b;17a;18a;		2		2			1	65.00	65.00	2	
H5216	062	0	1	04	01	H5216_062_0	3	3		01	12;		2		1	20	20	2			2	
H5216	062	0	1	04	01	H5216_062_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	062	0	1	04	01	H5216_062_0	3	5		01	15;		2		1	20	50	2			2	
H5216	062	0	1	04	01	H5216_062_0	3	6		01	11b;		2		1	25	25	2			2	
H5216	062	0	1	04	01	H5216_062_0	3	7		01	11a;		2		1	30	30	2			2	
H5216	062	0	1	04	01	H5216_062_0	3	8		11	6;9a;9b;11c;14d;14e;	14b;14c;16a;16b;	2		1	50	50	2			2	
H5216	062	0	1	04	01	H5216_062_0	3	9		10		13b;	1	25.00	1	50	50	2			2	
H5216	063	0	1	04	01	H5216_063_0	3	1		11	9d;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	063	0	1	04	01	H5216_063_0	3	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	063	0	1	04	01	H5216_063_0	3	3		10		16a;	2		1	0	0	2			2	
H5216	063	0	1	04	01	H5216_063_0	3	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;	14b;	2		1	20	20	2			2	
H5216	063	0	1	04	01	H5216_063_0	3	5		01	14a;		2		1	20	20	1	0.00	0.00	2	
H5216	063	0	1	04	01	H5216_063_0	3	6		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	063	0	1	04	01	H5216_063_0	3	7		10		13c;14c;	2		1	50	50	2			2	
H5216	063	0	1	04	01	H5216_063_0	3	8		10		16b;	2		1	50	70	2			2	
H5216	064	0	1	04	01	H5216_064_0	3	1		11	9d;17b;	9d;17a;18a;	2		2			1	0.00	0.00	2	
H5216	064	0	1	04	01	H5216_064_0	3	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	064	0	1	04	01	H5216_064_0	3	3		01	12;		2		1	20	20	2			2	
H5216	064	0	1	04	01	H5216_064_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	064	0	1	04	01	H5216_064_0	3	5		01	11a;		2		1	22	22	2			2	
H5216	064	0	1	04	01	H5216_064_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	064	0	1	04	01	H5216_064_0	3	7		01	14a;		2		1	30	50	1	0.00	0.00	2	
H5216	064	0	1	04	01	H5216_064_0	3	8		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	064	0	1	04	01	H5216_064_0	3	9		10		13b;	1	25.00	1	50	50	2			2	
H5216	065	0	1	04	01	H5216_065_0	3	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5216	065	0	1	04	01	H5216_065_0	3	10		01	14a;		2		1	50	50	1	0.00	50.00	2	
H5216	065	0	1	04	01	H5216_065_0	3	11		01	3-1;3-2;3-3;7c;7i;8a1;8a2;8b1;8b2;8b3;9c;14e;		2		1	50	50	1	50.00	50.00	2	
H5216	065	0	1	04	01	H5216_065_0	3	2		10		14b;	2		2			1	40.00	40.00	2	
H5216	065	0	1	04	01	H5216_065_0	3	3		01	7a;7b;7d;7e;7f;7g;7h;14d;16b;17a;18a;		2		2			1	50.00	50.00	2	
H5216	065	0	1	04	01	H5216_065_0	3	4		01	12;		2		1	20	20	2			2	
H5216	065	0	1	04	01	H5216_065_0	3	5		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	065	0	1	04	01	H5216_065_0	3	6		01	15;		2		1	20	50	2			2	
H5216	065	0	1	04	01	H5216_065_0	3	7		01	11b;		2		1	25	25	2			2	
H5216	065	0	1	04	01	H5216_065_0	3	8		11	5;6;9a;9b;11a;11c;	13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	065	0	1	04	01	H5216_065_0	3	9		10		13b;	1	10.00	1	50	50	2			2	
H5216	066	0	1	04	01	H5216_066_0	2	1		11	9d;17b;	9d;17a;18a;	2		2			1	0.00	0.00	2	
H5216	066	0	1	04	01	H5216_066_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	066	0	1	04	01	H5216_066_0	2	3		01	11a;12;		2		1	20	20	2			2	
H5216	066	0	1	04	01	H5216_066_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	066	0	1	04	01	H5216_066_0	2	5		01	11c;		2		1	20	40	2			2	
H5216	066	0	1	04	01	H5216_066_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	066	0	1	04	01	H5216_066_0	2	7		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	066	0	1	04	01	H5216_066_0	2	8		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	066	0	1	04	01	H5216_066_0	2	9		10		13b;	1	25.00	1	50	50	2			2	
H5216	067	0	1	04	01	H5216_067_0	2	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	067	0	1	04	01	H5216_067_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	067	0	1	04	01	H5216_067_0	2	3		01	11a;12;		2		1	20	20	2			2	
H5216	067	0	1	04	01	H5216_067_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	067	0	1	04	01	H5216_067_0	2	5		01	11b;11c;		2		1	25	25	2			2	
H5216	067	0	1	04	01	H5216_067_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;15;16b;17a;18a;	14b;	2		1	35	35	2			2	
H5216	067	0	1	04	01	H5216_067_0	2	7		01	14a;		2		1	35	35	1	0.00	0.00	2	
H5216	067	0	1	04	01	H5216_067_0	2	8		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	067	0	1	04	01	H5216_067_0	2	9		10		13b;	1	30.00	1	50	50	2			2	
H5216	068	0	1	04	01	H5216_068_0	4	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5216	068	0	1	04	01	H5216_068_0	4	10		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	068	0	1	04	01	H5216_068_0	4	11		01	3-1;3-2;3-3;7c;7i;8a1;8a2;8b1;8b2;8b3;9c;		2		1	50	50	1	65.00	65.00	2	
H5216	068	0	1	04	01	H5216_068_0	4	2		01	5;7a;7b;7d;7e;7f;7g;7h;16b;17a;18a;		2		2			1	65.00	65.00	2	
H5216	068	0	1	04	01	H5216_068_0	4	3		01	12;		2		1	20	20	2			2	
H5216	068	0	1	04	01	H5216_068_0	4	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	068	0	1	04	01	H5216_068_0	4	5		01	15;		2		1	20	50	2			2	
H5216	068	0	1	04	01	H5216_068_0	4	6		01	11b;		2		1	25	25	2			2	
H5216	068	0	1	04	01	H5216_068_0	4	7		01	11a;		2		1	30	30	2			2	
H5216	068	0	1	04	01	H5216_068_0	4	8		11	6;9a;9b;11c;14d;14e;	14b;14c;16a;16b;	2		1	50	50	2			2	
H5216	068	0	1	04	01	H5216_068_0	4	9		10		13b;	1	45.00	1	50	50	2			2	
H5216	070	0	1	04	01	H5216_070_0	3	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H5216	070	0	1	04	01	H5216_070_0	3	10		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	070	0	1	04	01	H5216_070_0	3	11		01	3-1;3-2;3-3;7c;7i;8a1;8a2;8b1;8b2;8b3;9c;		2		1	50	50	1	65.00	65.00	2	
H5216	070	0	1	04	01	H5216_070_0	3	2		01	5;7a;7b;7d;7e;7f;7g;7h;16b;17a;18a;		2		2			1	65.00	65.00	2	
H5216	070	0	1	04	01	H5216_070_0	3	3		01	12;		2		1	20	20	2			2	
H5216	070	0	1	04	01	H5216_070_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	070	0	1	04	01	H5216_070_0	3	5		01	15;		2		1	20	50	2			2	
H5216	070	0	1	04	01	H5216_070_0	3	6		01	11b;		2		1	25	25	2			2	
H5216	070	0	1	04	01	H5216_070_0	3	7		01	11a;		2		1	30	30	2			2	
H5216	070	0	1	04	01	H5216_070_0	3	8		11	6;9a;9b;11c;14d;14e;	14b;14c;16a;16b;	2		1	50	50	2			2	
H5216	070	0	1	04	01	H5216_070_0	3	9		10		13b;	1	30.00	1	50	50	2			2	
H5216	071	0	1	04	01	H5216_071_0	3	1		11	9d;17b;	9d;18a;	2		2			1	0.00	0.00	2	
H5216	071	0	1	04	01	H5216_071_0	3	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	071	0	1	04	01	H5216_071_0	3	3		01	11a;11b;12;		2		1	20	20	2			2	
H5216	071	0	1	04	01	H5216_071_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	071	0	1	04	01	H5216_071_0	3	5		01	11c;		2		1	25	25	2			2	
H5216	071	0	1	04	01	H5216_071_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	071	0	1	04	01	H5216_071_0	3	7		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	071	0	1	04	01	H5216_071_0	3	8		10		13c;14c;16a;	2		1	50	50	2			2	
H5216	071	0	1	04	01	H5216_071_0	3	9		10		13b;	1	25.00	1	50	50	2			2	
H5216	072	0	1	04	01	H5216_072_0	3	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5216	072	0	1	04	01	H5216_072_0	3	10		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	072	0	1	04	01	H5216_072_0	3	11		01	3-1;3-2;3-3;7c;7i;8a1;8a2;8b1;8b2;8b3;9c;		2		1	50	50	1	65.00	65.00	2	
H5216	072	0	1	04	01	H5216_072_0	3	2		01	5;7a;7b;7d;7e;7f;7g;7h;16b;17a;18a;		2		2			1	65.00	65.00	2	
H5216	072	0	1	04	01	H5216_072_0	3	3		01	12;		2		1	20	20	2			2	
H5216	072	0	1	04	01	H5216_072_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	072	0	1	04	01	H5216_072_0	3	5		01	15;		2		1	20	50	2			2	
H5216	072	0	1	04	01	H5216_072_0	3	6		01	11b;		2		1	25	25	2			2	
H5216	072	0	1	04	01	H5216_072_0	3	7		01	11a;		2		1	30	30	2			2	
H5216	072	0	1	04	01	H5216_072_0	3	8		11	6;9a;9b;11c;14d;14e;	14b;14c;16a;16b;	2		1	50	50	2			2	
H5216	072	0	1	04	01	H5216_072_0	3	9		10		13b;	1	45.00	1	50	50	2			2	
H5216	073	0	1	04	01	H5216_073_0	2	1		11	9d;17b;	9d;18a;	2		2			1	0.00	0.00	2	
H5216	073	0	1	04	01	H5216_073_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	073	0	1	04	01	H5216_073_0	2	3		01	11a;11b;12;		2		1	20	20	2			2	
H5216	073	0	1	04	01	H5216_073_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	073	0	1	04	01	H5216_073_0	2	5		01	11c;		2		1	25	25	2			2	
H5216	073	0	1	04	01	H5216_073_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	073	0	1	04	01	H5216_073_0	2	7		01	14a;		2		1	30	50	1	0.00	0.00	2	
H5216	073	0	1	04	01	H5216_073_0	2	8		10		13c;14c;	2		1	50	50	2			2	
H5216	073	0	1	04	01	H5216_073_0	2	9		10		13b;	1	25.00	1	50	50	2			2	
H5216	074	0	1	04	01	H5216_074_0	4	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5216	074	0	1	04	01	H5216_074_0	4	10		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	074	0	1	04	01	H5216_074_0	4	11		01	3-1;3-2;3-3;7c;7i;8a1;8a2;8b1;8b2;8b3;9c;		2		1	50	50	1	65.00	65.00	2	
H5216	074	0	1	04	01	H5216_074_0	4	2		01	5;7a;7b;7d;7e;7f;7g;7h;16b;17a;18a;		2		2			1	65.00	65.00	2	
H5216	074	0	1	04	01	H5216_074_0	4	3		01	12;		2		1	20	20	2			2	
H5216	074	0	1	04	01	H5216_074_0	4	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	074	0	1	04	01	H5216_074_0	4	5		01	15;		2		1	20	50	2			2	
H5216	074	0	1	04	01	H5216_074_0	4	6		11	11b;	18a;18b;	2		1	25	25	2			2	
H5216	074	0	1	04	01	H5216_074_0	4	7		01	11a;		2		1	30	30	2			2	
H5216	074	0	1	04	01	H5216_074_0	4	8		11	6;9a;9b;11c;14d;14e;	14b;14c;16a;16b;	2		1	50	50	2			2	
H5216	074	0	1	04	01	H5216_074_0	4	9		10		13b;	1	50.00	1	50	50	2			2	
H5216	075	0	1	04	01	H5216_075_0	2	1		11	9d;17b;	9d;18a;	2		2			1	0.00	0.00	2	
H5216	075	0	1	04	01	H5216_075_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	075	0	1	04	01	H5216_075_0	2	3		01	11a;11b;12;		2		1	20	20	2			2	
H5216	075	0	1	04	01	H5216_075_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	075	0	1	04	01	H5216_075_0	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11c;14d;14e;15;16b;17a;18a;	14b;	2		1	40	40	2			2	
H5216	075	0	1	04	01	H5216_075_0	2	6		01	14a;		2		1	40	40	1	0.00	0.00	2	
H5216	075	0	1	04	01	H5216_075_0	2	7		10		13c;14c;	2		1	50	50	2			2	
H5216	075	0	1	04	01	H5216_075_0	2	8		10		13b;	1	25.00	1	50	50	2			2	
H5216	076	0	1	04	01	H5216_076_0	2	1		11	9d;17b;	9d;17a;18a;	2		2			1	0.00	0.00	2	
H5216	076	0	1	04	01	H5216_076_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	076	0	1	04	01	H5216_076_0	2	3		01	12;		2		1	20	20	2			2	
H5216	076	0	1	04	01	H5216_076_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	076	0	1	04	01	H5216_076_0	2	5		01	11a;		2		1	25	25	2			2	
H5216	076	0	1	04	01	H5216_076_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	076	0	1	04	01	H5216_076_0	2	7		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	076	0	1	04	01	H5216_076_0	2	8		10		13c;14c;	2		1	50	50	2			2	
H5216	076	0	1	04	01	H5216_076_0	2	9		10		13b;	1	25.00	1	50	50	2			2	
H5216	077	0	1	04	01	H5216_077_0	3	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	077	0	1	04	01	H5216_077_0	3	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	077	0	1	04	01	H5216_077_0	3	3		01	11a;11b;11c;12;		2		1	20	20	2			2	
H5216	077	0	1	04	01	H5216_077_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	077	0	1	04	01	H5216_077_0	3	5		01	15;		2		1	20	30	2			2	
H5216	077	0	1	04	01	H5216_077_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	7f;14b;	2		1	30	30	2			2	
H5216	077	0	1	04	01	H5216_077_0	3	7		01	14a;		2		1	30	50	1	0.00	0.00	2	
H5216	077	0	1	04	01	H5216_077_0	3	8		10		10b;13a;13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	077	0	1	04	01	H5216_077_0	3	9		10		13b;	1	25.00	1	50	50	2			2	
H5216	078	1	1	04	01	H5216_078_1	2	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	078	1	1	04	01	H5216_078_1	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	078	1	1	04	01	H5216_078_1	2	3		01	12;		2		1	20	20	2			2	
H5216	078	1	1	04	01	H5216_078_1	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	078	1	1	04	01	H5216_078_1	2	5		01	11a;		2		1	25	25	2			2	
H5216	078	1	1	04	01	H5216_078_1	2	6		01	14a;		2		1	30	40	1	0.00	0.00	2	
H5216	078	1	1	04	01	H5216_078_1	2	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	14b;	2		1	40	40	2			2	
H5216	078	1	1	04	01	H5216_078_1	2	8		10		13c;14c;	2		1	50	50	2			2	
H5216	078	1	1	04	01	H5216_078_1	2	9		10		13b;	1	25.00	1	50	50	2			2	
H5216	078	2	1	04	01	H5216_078_2	2	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	078	2	1	04	01	H5216_078_2	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	078	2	1	04	01	H5216_078_2	2	3		01	12;		2		1	20	20	2			2	
H5216	078	2	1	04	01	H5216_078_2	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	078	2	1	04	01	H5216_078_2	2	5		01	11a;		2		1	25	25	2			2	
H5216	078	2	1	04	01	H5216_078_2	2	6		01	14a;		2		1	30	40	1	0.00	0.00	2	
H5216	078	2	1	04	01	H5216_078_2	2	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	14b;	2		1	40	40	2			2	
H5216	078	2	1	04	01	H5216_078_2	2	8		10		13c;14c;	2		1	50	50	2			2	
H5216	078	2	1	04	01	H5216_078_2	2	9		10		13b;	1	25.00	1	50	50	2			2	
H5216	079	0	1	04	01	H5216_079_0	5	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	079	0	1	04	01	H5216_079_0	5	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	079	0	1	04	01	H5216_079_0	5	3		01	6;11a;12;		2		1	20	20	2			2	
H5216	079	0	1	04	01	H5216_079_0	5	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	079	0	1	04	01	H5216_079_0	5	5		01	14a;		2		1	30	40	1	0.00	0.00	2	
H5216	079	0	1	04	01	H5216_079_0	5	6		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	14b;	2		1	40	40	2			2	
H5216	079	0	1	04	01	H5216_079_0	5	7		10		13c;14c;	2		1	50	50	2			2	
H5216	079	0	1	04	01	H5216_079_0	5	8		10		13b;	1	50.00	1	50	50	2			2	
H5216	080	1	1	04	01	H5216_080_1	2	1		11	9d;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	080	1	1	04	01	H5216_080_1	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	080	1	1	04	01	H5216_080_1	2	3		01	11a;12;		2		1	20	20	2			2	
H5216	080	1	1	04	01	H5216_080_1	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	080	1	1	04	01	H5216_080_1	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;14b;14c;16a;	2		1	50	50	2			2	
H5216	080	1	1	04	01	H5216_080_1	2	6		10		13b;	1	50.00	1	50	50	2			2	
H5216	080	1	1	04	01	H5216_080_1	2	7		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	080	1	1	04	01	H5216_080_1	2	8		10		16b;	2		1	50	75	2			2	
H5216	080	2	1	04	01	H5216_080_2	2	1		11	9d;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	080	2	1	04	01	H5216_080_2	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	080	2	1	04	01	H5216_080_2	2	3		01	11a;12;		2		1	20	20	2			2	
H5216	080	2	1	04	01	H5216_080_2	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	080	2	1	04	01	H5216_080_2	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;14b;14c;16a;	2		1	50	50	2			2	
H5216	080	2	1	04	01	H5216_080_2	2	6		10		13b;	1	50.00	1	50	50	2			2	
H5216	080	2	1	04	01	H5216_080_2	2	7		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	080	2	1	04	01	H5216_080_2	2	8		10		16b;	2		1	50	75	2			2	
H5216	080	3	1	04	01	H5216_080_3	2	1		11	9d;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	080	3	1	04	01	H5216_080_3	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	080	3	1	04	01	H5216_080_3	2	3		01	11a;12;		2		1	20	20	2			2	
H5216	080	3	1	04	01	H5216_080_3	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	080	3	1	04	01	H5216_080_3	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;14b;14c;16a;	2		1	50	50	2			2	
H5216	080	3	1	04	01	H5216_080_3	2	6		10		13b;	1	50.00	1	50	50	2			2	
H5216	080	3	1	04	01	H5216_080_3	2	7		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	080	3	1	04	01	H5216_080_3	2	8		10		16b;	2		1	50	75	2			2	
H5216	081	0	1	04	01	H5216_081_0	3	1		11	9d;17b;	9d;18a;	2		2			1	0.00	0.00	2	
H5216	081	0	1	04	01	H5216_081_0	3	10		10		13b;	1	25.00	1	50	50	2			2	
H5216	081	0	1	04	01	H5216_081_0	3	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	081	0	1	04	01	H5216_081_0	3	3		01	12;		2		1	20	20	2			2	
H5216	081	0	1	04	01	H5216_081_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	081	0	1	04	01	H5216_081_0	3	5		01	15;		2		1	20	30	2			2	
H5216	081	0	1	04	01	H5216_081_0	3	6		01	11a;		2		1	25	25	2			2	
H5216	081	0	1	04	01	H5216_081_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	081	0	1	04	01	H5216_081_0	3	8		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	081	0	1	04	01	H5216_081_0	3	9		10		13c;14c;16a;	2		1	50	50	2			2	
H5216	082	0	1	04	01	H5216_082_0	2	1		11	9d;	9d;17a;18a;	2		2			1	0.00	0.00	2	
H5216	082	0	1	04	01	H5216_082_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	082	0	1	04	01	H5216_082_0	2	3		01	12;		2		1	20	20	2			2	
H5216	082	0	1	04	01	H5216_082_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	082	0	1	04	01	H5216_082_0	2	5		01	15;		2		1	20	50	2			2	
H5216	082	0	1	04	01	H5216_082_0	2	6		01	11a;		2		1	30	30	2			2	
H5216	082	0	1	04	01	H5216_082_0	2	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;17b;18a;	13c;14b;14c;16a;	2		1	50	50	2			2	
H5216	082	0	1	04	01	H5216_082_0	2	8		10		13b;	1	25.00	1	50	50	2			2	
H5216	082	0	1	04	01	H5216_082_0	2	9		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	083	0	1	04	01	H5216_083_0	2	1		11	9d;	9d;17a;	2		2			1	0.00	0.00	2	
H5216	083	0	1	04	01	H5216_083_0	2	2		01	11a;		2		1	19	19	2			2	
H5216	083	0	1	04	01	H5216_083_0	2	3		01	12;15;		2		1	20	20	2			2	
H5216	083	0	1	04	01	H5216_083_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	083	0	1	04	01	H5216_083_0	2	5		01	11b;11c;		2		1	20	50	2			2	
H5216	083	0	1	04	01	H5216_083_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;17b;18a;	13c;14b;14c;	2		1	50	50	2			2	
H5216	083	0	1	04	01	H5216_083_0	2	7		10		13b;	1	25.00	1	50	50	2			2	
H5216	083	0	1	04	01	H5216_083_0	2	8		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	084	0	1	04	01	H5216_084_0	2	1		11	9d;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5216	084	0	1	04	01	H5216_084_0	2	2		01	11a;12;		2		1	20	20	2			2	
H5216	084	0	1	04	01	H5216_084_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	084	0	1	04	01	H5216_084_0	2	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;14b;14c;16a;	2		1	50	50	2			2	
H5216	084	0	1	04	01	H5216_084_0	2	5		10		13b;	1	25.00	1	50	50	2			2	
H5216	084	0	1	04	01	H5216_084_0	2	6		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	084	0	1	04	01	H5216_084_0	2	7		10		16b;	2		1	50	75	2			2	
H5216	085	0	1	04	01	H5216_085_0	2	1		11	9d;	9d;	2		2			1	0.00	0.00	2	
H5216	085	0	1	04	01	H5216_085_0	2	2		01	11a;12;		2		1	20	20	2			2	
H5216	085	0	1	04	01	H5216_085_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	085	0	1	04	01	H5216_085_0	2	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;14b;14c;	2		1	50	50	2			2	
H5216	085	0	1	04	01	H5216_085_0	2	5		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	086	0	1	04	01	H5216_086_0	3	1		11	9d;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	086	0	1	04	01	H5216_086_0	3	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	086	0	1	04	01	H5216_086_0	3	3		01	11a;		2		1	10	10	2			2	
H5216	086	0	1	04	01	H5216_086_0	3	4		01	12;		2		1	20	20	2			2	
H5216	086	0	1	04	01	H5216_086_0	3	5		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	086	0	1	04	01	H5216_086_0	3	6		01	11c;		2		1	20	50	2			2	
H5216	086	0	1	04	01	H5216_086_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;15;16b;17a;17b;18a;	13c;14b;14c;16a;16b;	2		1	50	50	2			2	
H5216	086	0	1	04	01	H5216_086_0	3	8		10		13b;	1	75.00	1	50	50	2			2	
H5216	086	0	1	04	01	H5216_086_0	3	9		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	087	0	1	04	01	H5216_087_0	2	1		11	9d;	9d;	2		2			1	0.00	0.00	2	
H5216	087	0	1	04	01	H5216_087_0	2	2		01	11a;12;		2		1	20	20	2			2	
H5216	087	0	1	04	01	H5216_087_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	087	0	1	04	01	H5216_087_0	2	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;14b;14c;	2		1	50	50	2			2	
H5216	087	0	1	04	01	H5216_087_0	2	5		10		13b;	1	25.00	1	50	50	2			2	
H5216	087	0	1	04	01	H5216_087_0	2	6		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	088	0	1	04	01	H5216_088_0	3	1		11	9d;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5216	088	0	1	04	01	H5216_088_0	3	2		01	11a;12;		2		1	20	20	2			2	
H5216	088	0	1	04	01	H5216_088_0	3	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	088	0	1	04	01	H5216_088_0	3	4		01	11c;		2		1	20	50	2			2	
H5216	088	0	1	04	01	H5216_088_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;15;16b;17a;17b;18a;	13c;14b;14c;16a;	2		1	50	50	2			2	
H5216	088	0	1	04	01	H5216_088_0	3	6		10		13b;	1	25.00	1	50	50	2			2	
H5216	088	0	1	04	01	H5216_088_0	3	7		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	088	0	1	04	01	H5216_088_0	3	8		10		16b;	2		1	50	55	2			2	
H5216	089	0	1	04	01	H5216_089_0	2	1		11	9d;	9d;	2		2			1	0.00	0.00	2	
H5216	089	0	1	04	01	H5216_089_0	2	2		01	11a;12;		2		1	20	20	2			2	
H5216	089	0	1	04	01	H5216_089_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	089	0	1	04	01	H5216_089_0	2	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;14b;14c;	2		1	50	50	2			2	
H5216	089	0	1	04	01	H5216_089_0	2	5		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	091	0	1	04	01	H5216_091_0	2	1		11	9d;	9d;	2		2			1	0.00	0.00	2	
H5216	091	0	1	04	01	H5216_091_0	2	2		01	11a;12;		2		1	20	20	2			2	
H5216	091	0	1	04	01	H5216_091_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	091	0	1	04	01	H5216_091_0	2	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;14b;14c;	2		1	50	50	2			2	
H5216	091	0	1	04	01	H5216_091_0	2	5		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	092	0	1	04	01	H5216_092_0	2	1		11	6;9d;	9d;	2		2			1	0.00	0.00	2	
H5216	092	0	1	04	01	H5216_092_0	2	2		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;	14b;	2		1	20	20	2			2	
H5216	092	0	1	04	01	H5216_092_0	2	3		01	14a;		2		1	20	20	1	0.00	0.00	2	
H5216	092	0	1	04	01	H5216_092_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	092	0	1	04	01	H5216_092_0	2	5		10		13c;14c;	2		1	50	50	2			2	
H5216	092	0	1	04	01	H5216_092_0	2	6		10		13b;	1	50.00	1	50	50	2			2	
H5216	093	0	1	04	01	H5216_093_0	3	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H5216	093	0	1	04	01	H5216_093_0	3	2		01	11a;11c;12;		2		1	20	20	2			2	
H5216	093	0	1	04	01	H5216_093_0	3	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	093	0	1	04	01	H5216_093_0	3	4		01	15;		2		1	20	30	2			2	
H5216	093	0	1	04	01	H5216_093_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	093	0	1	04	01	H5216_093_0	3	6		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	093	0	1	04	01	H5216_093_0	3	7		10		13c;14c;	2		1	50	50	2			2	
H5216	093	0	1	04	01	H5216_093_0	3	8		10		13b;	1	25.00	1	50	50	2			2	
H5216	094	0	1	04	01	H5216_094_0	2	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H5216	094	0	1	04	01	H5216_094_0	2	2		01	11a;11c;12;		2		1	20	20	2			2	
H5216	094	0	1	04	01	H5216_094_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	094	0	1	04	01	H5216_094_0	2	4		01	15;		2		1	20	40	2			2	
H5216	094	0	1	04	01	H5216_094_0	2	5		01	11b;		2		1	25	25	2			2	
H5216	094	0	1	04	01	H5216_094_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	14b;	2		1	40	40	2			2	
H5216	094	0	1	04	01	H5216_094_0	2	7		01	14a;		2		1	40	40	1	0.00	0.00	2	
H5216	094	0	1	04	01	H5216_094_0	2	8		10		13c;14c;	2		1	50	50	2			2	
H5216	094	0	1	04	01	H5216_094_0	2	9		10		13b;	1	25.00	1	50	50	2			2	
H5216	095	0	1	04	01	H5216_095_0	2	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H5216	095	0	1	04	01	H5216_095_0	2	2		01	12;		2		1	20	20	2			2	
H5216	095	0	1	04	01	H5216_095_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	095	0	1	04	01	H5216_095_0	2	4		01	15;		2		1	20	40	2			2	
H5216	095	0	1	04	01	H5216_095_0	2	5		01	11a;11b;11c;		2		1	25	25	2			2	
H5216	095	0	1	04	01	H5216_095_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	14b;	2		1	40	40	2			2	
H5216	095	0	1	04	01	H5216_095_0	2	7		01	14a;		2		1	40	40	1	0.00	0.00	2	
H5216	095	0	1	04	01	H5216_095_0	2	8		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	095	0	1	04	01	H5216_095_0	2	9		10		13b;	1	30.00	1	50	50	2			2	
H5216	096	0	1	04	01	H5216_096_0	4	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H5216	096	0	1	04	01	H5216_096_0	4	2		01	12;		2		1	20	20	2			2	
H5216	096	0	1	04	01	H5216_096_0	4	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	096	0	1	04	01	H5216_096_0	4	4		01	15;		2		1	20	30	2			2	
H5216	096	0	1	04	01	H5216_096_0	4	5		01	11a;11b;11c;		2		1	25	25	2			2	
H5216	096	0	1	04	01	H5216_096_0	4	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	096	0	1	04	01	H5216_096_0	4	7		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	096	0	1	04	01	H5216_096_0	4	8		10		13c;14c;	2		1	50	50	2			2	
H5216	096	0	1	04	01	H5216_096_0	4	9		10		13b;	1	30.00	1	50	50	2			2	
H5216	097	0	1	04	01	H5216_097_0	2	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H5216	097	0	1	04	01	H5216_097_0	2	2		01	11a;11c;12;		2		1	20	20	2			2	
H5216	097	0	1	04	01	H5216_097_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	097	0	1	04	01	H5216_097_0	2	4		01	15;		2		1	20	40	2			2	
H5216	097	0	1	04	01	H5216_097_0	2	5		01	11b;		2		1	25	25	2			2	
H5216	097	0	1	04	01	H5216_097_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	14b;	2		1	40	40	2			2	
H5216	097	0	1	04	01	H5216_097_0	2	7		01	14a;		2		1	40	40	1	0.00	0.00	2	
H5216	097	0	1	04	01	H5216_097_0	2	8		10		13c;14c;	2		1	50	50	2			2	
H5216	097	0	1	04	01	H5216_097_0	2	9		10		13b;	1	25.00	1	50	50	2			2	
H5216	098	0	1	04	01	H5216_098_0	2	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H5216	098	0	1	04	01	H5216_098_0	2	2		01	12;		2		1	20	20	2			2	
H5216	098	0	1	04	01	H5216_098_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	098	0	1	04	01	H5216_098_0	2	4		01	15;		2		1	20	30	2			2	
H5216	098	0	1	04	01	H5216_098_0	2	5		01	11a;11b;11c;		2		1	25	25	2			2	
H5216	098	0	1	04	01	H5216_098_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	098	0	1	04	01	H5216_098_0	2	7		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	098	0	1	04	01	H5216_098_0	2	8		10		13c;14c;	2		1	50	50	2			2	
H5216	099	0	1	04	01	H5216_099_0	2	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H5216	099	0	1	04	01	H5216_099_0	2	2		01	11a;11c;12;		2		1	20	20	2			2	
H5216	099	0	1	04	01	H5216_099_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	099	0	1	04	01	H5216_099_0	2	4		01	15;		2		1	20	30	2			2	
H5216	099	0	1	04	01	H5216_099_0	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	099	0	1	04	01	H5216_099_0	2	6		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	099	0	1	04	01	H5216_099_0	2	7		10		13c;14c;	2		1	50	50	2			2	
H5216	100	0	1	04	01	H5216_100_0	2	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5216	100	0	1	04	01	H5216_100_0	2	2		01	11a;11c;12;		2		1	20	20	2			2	
H5216	100	0	1	04	01	H5216_100_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	100	0	1	04	01	H5216_100_0	2	4		01	15;		2		1	20	30	2			2	
H5216	100	0	1	04	01	H5216_100_0	2	5		01	11b;		2		1	25	25	2			2	
H5216	100	0	1	04	01	H5216_100_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	100	0	1	04	01	H5216_100_0	2	7		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	100	0	1	04	01	H5216_100_0	2	8		10		13c;14c;	2		1	50	50	2			2	
H5216	100	0	1	04	01	H5216_100_0	2	9		10		13b;	1	25.00	1	50	50	2			2	
H5216	103	0	1	04	01	H5216_103_0	2	1		11	9d;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	103	0	1	04	01	H5216_103_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	103	0	1	04	01	H5216_103_0	2	3		10		16a;	2		1	0	0	2			2	
H5216	103	0	1	04	01	H5216_103_0	2	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;	14b;	2		1	20	20	2			2	
H5216	103	0	1	04	01	H5216_103_0	2	5		01	14a;		2		1	20	20	1	0.00	0.00	2	
H5216	103	0	1	04	01	H5216_103_0	2	6		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	103	0	1	04	01	H5216_103_0	2	7		10		13c;14c;	2		1	50	50	2			2	
H5216	103	0	1	04	01	H5216_103_0	2	8		10		16b;	2		1	50	70	2			2	
H5216	104	0	1	04	01	H5216_104_0	2	1		11	9d;	9d;18a;	2		2			1	0.00	0.00	2	
H5216	104	0	1	04	01	H5216_104_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	104	0	1	04	01	H5216_104_0	2	3		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;	14b;	2		1	20	20	2			2	
H5216	104	0	1	04	01	H5216_104_0	2	4		01	14a;		2		1	20	20	1	0.00	0.00	2	
H5216	104	0	1	04	01	H5216_104_0	2	5		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	104	0	1	04	01	H5216_104_0	2	6		10		13c;14c;	2		1	50	50	2			2	
H5216	105	0	1	04	01	H5216_105_0	2	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	105	0	1	04	01	H5216_105_0	2	2		10		18b;	2		2			1	499.00	799.00	2	
H5216	105	0	1	04	01	H5216_105_0	2	3		01	12;		2		1	20	20	2			2	
H5216	105	0	1	04	01	H5216_105_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	105	0	1	04	01	H5216_105_0	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	105	0	1	04	01	H5216_105_0	2	6		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	105	0	1	04	01	H5216_105_0	2	7		10		13c;14c;16a;	2		1	50	50	2			2	
H5216	105	0	1	04	01	H5216_105_0	2	8		10		13b;	1	75.00	1	50	50	2			2	
H5216	105	0	1	04	01	H5216_105_0	2	9		10		16b;	2		1	50	55	2			2	
H5216	106	0	1	04	01	H5216_106_0	2	1		11	9d;17b;	9d;18a;	2		2			1	0.00	0.00	2	
H5216	106	0	1	04	01	H5216_106_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	106	0	1	04	01	H5216_106_0	2	3		01	11a;12;		2		1	20	20	2			2	
H5216	106	0	1	04	01	H5216_106_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	106	0	1	04	01	H5216_106_0	2	5		01	15;		2		1	20	50	2			2	
H5216	106	0	1	04	01	H5216_106_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13c;14b;14c;	2		1	50	50	2			2	
H5216	106	0	1	04	01	H5216_106_0	2	7		10		13b;	1	30.00	1	50	50	2			2	
H5216	106	0	1	04	01	H5216_106_0	2	8		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	107	0	1	04	01	H5216_107_0	2	1		11	6;9d;14a;14d;14e;17b;	9d;14b;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	107	0	1	04	01	H5216_107_0	2	10		01	11c;		2		1	10	20	1	10.00	10.00	2	
H5216	107	0	1	04	01	H5216_107_0	2	11		01	11a;11b;12;15;		2		1	20	20	2			2	
H5216	107	0	1	04	01	H5216_107_0	2	12		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	107	0	1	04	01	H5216_107_0	2	13		01	8b2;		2		1	20	20	1	30.00	30.00	2	
H5216	107	0	1	04	01	H5216_107_0	2	14		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	107	0	1	04	01	H5216_107_0	2	15		10		13b;	1	75.00	1	50	50	2			2	
H5216	107	0	1	04	01	H5216_107_0	2	2		01	8a1;8a2;17a;		2		2			1	0.00	90.00	2	
H5216	107	0	1	04	01	H5216_107_0	2	3		01	3-1;3-2;3-3;7c;7i;		2		2			1	10.00	40.00	2	
H5216	107	0	1	04	01	H5216_107_0	2	4		01	9b;		2		2			1	150.00	150.00	2	
H5216	107	0	1	04	01	H5216_107_0	2	5		01	7b;		2		2			1	20.00	20.00	2	
H5216	107	0	1	04	01	H5216_107_0	2	6		01	9a;		2		2			1	250.00	250.00	2	
H5216	107	0	1	04	01	H5216_107_0	2	7		01	5;7d;7e;7f;7h;8b1;9c;16b;18a;		2		2			1	30.00	250.00	2	
H5216	107	0	1	04	01	H5216_107_0	2	8		10		18b;	2		2			1	399.00	699.00	2	
H5216	107	0	1	04	01	H5216_107_0	2	9		01	7a;7g;8b3;		2		2			1	5.00	90.00	2	
H5216	108	0	1	04	01	H5216_108_0	2	1		11	9d;17b;	9d;18a;	2		2			1	0.00	0.00	2	
H5216	108	0	1	04	01	H5216_108_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	108	0	1	04	01	H5216_108_0	2	3		01	11a;12;		2		1	20	20	2			2	
H5216	108	0	1	04	01	H5216_108_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	108	0	1	04	01	H5216_108_0	2	5		01	15;		2		1	20	50	2			2	
H5216	108	0	1	04	01	H5216_108_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13c;14b;14c;	2		1	50	50	2			2	
H5216	108	0	1	04	01	H5216_108_0	2	7		10		13b;	1	30.00	1	50	50	2			2	
H5216	108	0	1	04	01	H5216_108_0	2	8		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	109	0	1	04	01	H5216_109_0	2	1		11	9d;17b;	9d;18a;	2		2			1	0.00	0.00	2	
H5216	109	0	1	04	01	H5216_109_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	109	0	1	04	01	H5216_109_0	2	3		01	11a;12;		2		1	20	20	2			2	
H5216	109	0	1	04	01	H5216_109_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	109	0	1	04	01	H5216_109_0	2	5		01	15;		2		1	20	50	2			2	
H5216	109	0	1	04	01	H5216_109_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13c;14b;14c;	2		1	50	50	2			2	
H5216	109	0	1	04	01	H5216_109_0	2	7		10		13b;	1	30.00	1	50	50	2			2	
H5216	109	0	1	04	01	H5216_109_0	2	8		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	110	0	1	04	01	H5216_110_0	2	1		11	9d;17b;	9d;18a;	2		2			1	0.00	0.00	2	
H5216	110	0	1	04	01	H5216_110_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	110	0	1	04	01	H5216_110_0	2	3		01	11a;12;		2		1	20	20	2			2	
H5216	110	0	1	04	01	H5216_110_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	110	0	1	04	01	H5216_110_0	2	5		01	15;		2		1	20	50	2			2	
H5216	110	0	1	04	01	H5216_110_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13c;14b;14c;	2		1	50	50	2			2	
H5216	110	0	1	04	01	H5216_110_0	2	7		10		13b;	1	30.00	1	50	50	2			2	
H5216	110	0	1	04	01	H5216_110_0	2	8		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	111	0	1	04	01	H5216_111_0	2	1		11	9d;17b;	9d;18a;	2		2			1	0.00	0.00	2	
H5216	111	0	1	04	01	H5216_111_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	111	0	1	04	01	H5216_111_0	2	3		01	11a;12;		2		1	20	20	2			2	
H5216	111	0	1	04	01	H5216_111_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	111	0	1	04	01	H5216_111_0	2	5		01	15;		2		1	20	50	2			2	
H5216	111	0	1	04	01	H5216_111_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13c;14b;14c;	2		1	50	50	2			2	
H5216	111	0	1	04	01	H5216_111_0	2	7		10		13b;	1	30.00	1	50	50	2			2	
H5216	111	0	1	04	01	H5216_111_0	2	8		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	112	0	1	04	01	H5216_112_0	2	1		11	9d;17b;	9d;18a;	2		2			1	0.00	0.00	2	
H5216	112	0	1	04	01	H5216_112_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	112	0	1	04	01	H5216_112_0	2	3		01	11a;12;		2		1	20	20	2			2	
H5216	112	0	1	04	01	H5216_112_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	112	0	1	04	01	H5216_112_0	2	5		01	15;		2		1	20	50	2			2	
H5216	112	0	1	04	01	H5216_112_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13c;14b;14c;	2		1	50	50	2			2	
H5216	112	0	1	04	01	H5216_112_0	2	7		10		13b;	1	30.00	1	50	50	2			2	
H5216	112	0	1	04	01	H5216_112_0	2	8		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	113	0	1	04	01	H5216_113_0	2	1		11	9d;17b;	9d;18a;	2		2			1	0.00	0.00	2	
H5216	113	0	1	04	01	H5216_113_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	113	0	1	04	01	H5216_113_0	2	3		01	11a;12;		2		1	20	20	2			2	
H5216	113	0	1	04	01	H5216_113_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	113	0	1	04	01	H5216_113_0	2	5		01	15;		2		1	20	50	2			2	
H5216	113	0	1	04	01	H5216_113_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13c;14b;14c;	2		1	50	50	2			2	
H5216	113	0	1	04	01	H5216_113_0	2	7		10		13b;	1	30.00	1	50	50	2			2	
H5216	113	0	1	04	01	H5216_113_0	2	8		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	114	0	1	04	01	H5216_114_0	2	1		11	9d;17b;	9d;18a;	2		2			1	0.00	0.00	2	
H5216	114	0	1	04	01	H5216_114_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	114	0	1	04	01	H5216_114_0	2	3		01	11a;12;		2		1	20	20	2			2	
H5216	114	0	1	04	01	H5216_114_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	114	0	1	04	01	H5216_114_0	2	5		01	15;		2		1	20	50	2			2	
H5216	114	0	1	04	01	H5216_114_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13c;14b;14c;	2		1	50	50	2			2	
H5216	114	0	1	04	01	H5216_114_0	2	7		10		13b;	1	30.00	1	50	50	2			2	
H5216	114	0	1	04	01	H5216_114_0	2	8		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	115	0	1	04	01	H5216_115_0	3	1		11	6;9d;14a;14d;17b;	9d;14b;	2		2			1	0.00	0.00	2	
H5216	115	0	1	04	01	H5216_115_0	3	2		01	11a;		2		1	18	18	2			2	
H5216	115	0	1	04	01	H5216_115_0	3	3		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;10a;11b;12;15;16b;17a;18a;		2		1	20	20	2			2	
H5216	115	0	1	04	01	H5216_115_0	3	4		01	8a2;11c;14e;		2		1	20	20	1	0.00	0.00	2	
H5216	115	0	1	04	01	H5216_115_0	3	5		10		13c;14c;	2		1	50	50	2			2	
H5216	115	0	1	04	01	H5216_115_0	3	6		10		13b;	1	15.00	1	50	50	2			2	
H5216	116	0	1	04	01	H5216_116_0	1	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	116	0	1	04	01	H5216_116_0	1	2		10		18b;	2		2			1	499.00	799.00	2	
H5216	116	0	1	04	01	H5216_116_0	1	3		01	11a;12;		2		1	20	20	2			2	
H5216	116	0	1	04	01	H5216_116_0	1	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	116	0	1	04	01	H5216_116_0	1	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	116	0	1	04	01	H5216_116_0	1	6		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	116	0	1	04	01	H5216_116_0	1	7		10		13c;14c;16a;	2		1	50	50	2			2	
H5216	116	0	1	04	01	H5216_116_0	1	8		10		13b;	1	75.00	1	50	50	2			2	
H5216	116	0	1	04	01	H5216_116_0	1	9		10		16b;	2		1	50	55	2			2	
H5216	117	0	1	04	01	H5216_117_0	3	1		11	6;9d;14a;14d;17b;	9d;14b;17a;	2		2			1	0.00	0.00	2	
H5216	117	0	1	04	01	H5216_117_0	3	2		01	11a;		2		1	18	18	2			2	
H5216	117	0	1	04	01	H5216_117_0	3	3		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;10a;11b;12;15;16b;17a;18a;		2		1	20	20	2			2	
H5216	117	0	1	04	01	H5216_117_0	3	4		01	8a2;11c;14e;		2		1	20	20	1	0.00	0.00	2	
H5216	117	0	1	04	01	H5216_117_0	3	5		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	117	0	1	04	01	H5216_117_0	3	6		10		13b;	1	15.00	1	50	50	2			2	
H5216	119	0	1	04	01	H5216_119_0	2	1		11	6;9d;14a;14d;14e;17b;	9d;14b;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	119	0	1	04	01	H5216_119_0	2	10		01	11c;		2		1	10	20	1	10.00	10.00	2	
H5216	119	0	1	04	01	H5216_119_0	2	11		01	11a;11b;12;15;		2		1	20	20	2			2	
H5216	119	0	1	04	01	H5216_119_0	2	12		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	119	0	1	04	01	H5216_119_0	2	13		01	8b2;		2		1	20	20	1	30.00	30.00	2	
H5216	119	0	1	04	01	H5216_119_0	2	14		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	119	0	1	04	01	H5216_119_0	2	15		10		13b;	1	75.00	1	50	50	2			2	
H5216	119	0	1	04	01	H5216_119_0	2	2		01	8a1;8a2;17a;		2		2			1	0.00	90.00	2	
H5216	119	0	1	04	01	H5216_119_0	2	3		01	3-1;3-2;3-3;7c;7i;		2		2			1	10.00	40.00	2	
H5216	119	0	1	04	01	H5216_119_0	2	4		01	9b;		2		2			1	150.00	150.00	2	
H5216	119	0	1	04	01	H5216_119_0	2	5		01	7b;		2		2			1	20.00	20.00	2	
H5216	119	0	1	04	01	H5216_119_0	2	6		01	9a;		2		2			1	250.00	250.00	2	
H5216	119	0	1	04	01	H5216_119_0	2	7		01	5;7d;7e;7f;7h;8b1;9c;16b;18a;		2		2			1	30.00	250.00	2	
H5216	119	0	1	04	01	H5216_119_0	2	8		10		18b;	2		2			1	399.00	699.00	2	
H5216	119	0	1	04	01	H5216_119_0	2	9		01	7a;7g;8b3;		2		2			1	5.00	90.00	2	
H5216	120	0	1	04	01	H5216_120_0	2	1		11	6;9d;14a;14d;14e;17b;	9d;14b;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	120	0	1	04	01	H5216_120_0	2	10		01	11c;		2		1	10	20	1	10.00	10.00	2	
H5216	120	0	1	04	01	H5216_120_0	2	11		01	11a;11b;12;15;		2		1	20	20	2			2	
H5216	120	0	1	04	01	H5216_120_0	2	12		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	120	0	1	04	01	H5216_120_0	2	13		01	8b2;		2		1	20	20	1	30.00	30.00	2	
H5216	120	0	1	04	01	H5216_120_0	2	14		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	120	0	1	04	01	H5216_120_0	2	15		10		13b;	1	75.00	1	50	50	2			2	
H5216	120	0	1	04	01	H5216_120_0	2	2		01	8a1;8a2;17a;		2		2			1	0.00	90.00	2	
H5216	120	0	1	04	01	H5216_120_0	2	3		01	3-1;3-2;3-3;7c;7i;		2		2			1	10.00	40.00	2	
H5216	120	0	1	04	01	H5216_120_0	2	4		01	9b;		2		2			1	150.00	150.00	2	
H5216	120	0	1	04	01	H5216_120_0	2	5		01	7b;		2		2			1	20.00	20.00	2	
H5216	120	0	1	04	01	H5216_120_0	2	6		01	9a;		2		2			1	250.00	250.00	2	
H5216	120	0	1	04	01	H5216_120_0	2	7		01	5;7d;7e;7f;7h;8b1;9c;16b;18a;		2		2			1	30.00	250.00	2	
H5216	120	0	1	04	01	H5216_120_0	2	8		10		18b;	2		2			1	399.00	699.00	2	
H5216	120	0	1	04	01	H5216_120_0	2	9		01	7a;7g;8b3;		2		2			1	5.00	90.00	2	
H5216	121	0	1	04	01	H5216_121_0	2	1		11	6;9d;14a;14d;14e;17b;	9d;14b;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	121	0	1	04	01	H5216_121_0	2	10		01	11c;		2		1	10	20	1	10.00	10.00	2	
H5216	121	0	1	04	01	H5216_121_0	2	11		01	11a;11b;12;15;		2		1	20	20	2			2	
H5216	121	0	1	04	01	H5216_121_0	2	12		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	121	0	1	04	01	H5216_121_0	2	13		01	8b2;		2		1	20	20	1	30.00	30.00	2	
H5216	121	0	1	04	01	H5216_121_0	2	14		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	121	0	1	04	01	H5216_121_0	2	15		10		13b;	1	75.00	1	50	50	2			2	
H5216	121	0	1	04	01	H5216_121_0	2	2		01	8a1;8a2;17a;		2		2			1	0.00	90.00	2	
H5216	121	0	1	04	01	H5216_121_0	2	3		01	3-1;3-2;3-3;7c;7i;		2		2			1	10.00	40.00	2	
H5216	121	0	1	04	01	H5216_121_0	2	4		01	9b;		2		2			1	150.00	150.00	2	
H5216	121	0	1	04	01	H5216_121_0	2	5		01	7b;		2		2			1	20.00	20.00	2	
H5216	121	0	1	04	01	H5216_121_0	2	6		01	9a;		2		2			1	250.00	250.00	2	
H5216	121	0	1	04	01	H5216_121_0	2	7		01	5;7d;7e;7f;7h;8b1;9c;16b;18a;		2		2			1	30.00	250.00	2	
H5216	121	0	1	04	01	H5216_121_0	2	8		10		18b;	2		2			1	399.00	699.00	2	
H5216	121	0	1	04	01	H5216_121_0	2	9		01	7a;7g;8b3;		2		2			1	5.00	90.00	2	
H5216	122	0	1	04	01	H5216_122_0	2	1		11	6;9d;14a;14d;14e;17b;	9d;14b;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	122	0	1	04	01	H5216_122_0	2	10		01	11c;		2		1	10	20	1	10.00	10.00	2	
H5216	122	0	1	04	01	H5216_122_0	2	11		01	11a;11b;12;15;		2		1	20	20	2			2	
H5216	122	0	1	04	01	H5216_122_0	2	12		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	122	0	1	04	01	H5216_122_0	2	13		01	8b2;		2		1	20	20	1	30.00	30.00	2	
H5216	122	0	1	04	01	H5216_122_0	2	14		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	122	0	1	04	01	H5216_122_0	2	15		10		13b;	1	45.00	1	50	50	2			2	
H5216	122	0	1	04	01	H5216_122_0	2	2		01	8a1;8a2;17a;		2		2			1	0.00	90.00	2	
H5216	122	0	1	04	01	H5216_122_0	2	3		01	3-1;3-2;3-3;7c;7i;		2		2			1	10.00	40.00	2	
H5216	122	0	1	04	01	H5216_122_0	2	4		01	9b;		2		2			1	150.00	150.00	2	
H5216	122	0	1	04	01	H5216_122_0	2	5		01	7b;		2		2			1	20.00	20.00	2	
H5216	122	0	1	04	01	H5216_122_0	2	6		01	9a;		2		2			1	250.00	250.00	2	
H5216	122	0	1	04	01	H5216_122_0	2	7		01	5;7d;7e;7f;7h;8b1;9c;16b;18a;		2		2			1	30.00	250.00	2	
H5216	122	0	1	04	01	H5216_122_0	2	8		10		18b;	2		2			1	399.00	699.00	2	
H5216	122	0	1	04	01	H5216_122_0	2	9		01	7a;7g;8b3;		2		2			1	5.00	90.00	2	
H5216	123	0	1	04	01	H5216_123_0	1	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	123	0	1	04	01	H5216_123_0	1	2		10		18b;	2		2			1	499.00	799.00	2	
H5216	123	0	1	04	01	H5216_123_0	1	3		01	12;		2		1	20	20	2			2	
H5216	123	0	1	04	01	H5216_123_0	1	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	123	0	1	04	01	H5216_123_0	1	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	123	0	1	04	01	H5216_123_0	1	6		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	123	0	1	04	01	H5216_123_0	1	7		10		13c;14c;16a;	2		1	50	50	2			2	
H5216	123	0	1	04	01	H5216_123_0	1	8		10		13b;	1	75.00	1	50	50	2			2	
H5216	123	0	1	04	01	H5216_123_0	1	9		10		16b;	2		1	50	55	2			2	
H5216	124	0	1	04	01	H5216_124_0	2	1		11	6;9d;14a;14d;14e;17b;	9d;14b;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	124	0	1	04	01	H5216_124_0	2	10		01	11c;		2		1	10	20	1	10.00	10.00	2	
H5216	124	0	1	04	01	H5216_124_0	2	11		01	11a;11b;12;15;		2		1	20	20	2			2	
H5216	124	0	1	04	01	H5216_124_0	2	12		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	124	0	1	04	01	H5216_124_0	2	13		01	8b2;		2		1	20	20	1	30.00	30.00	2	
H5216	124	0	1	04	01	H5216_124_0	2	14		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	124	0	1	04	01	H5216_124_0	2	15		10		13b;	1	75.00	1	50	50	2			2	
H5216	124	0	1	04	01	H5216_124_0	2	2		01	8a1;8a2;17a;		2		2			1	0.00	90.00	2	
H5216	124	0	1	04	01	H5216_124_0	2	3		01	3-1;3-2;3-3;7c;7i;		2		2			1	10.00	40.00	2	
H5216	124	0	1	04	01	H5216_124_0	2	4		01	9b;		2		2			1	150.00	150.00	2	
H5216	124	0	1	04	01	H5216_124_0	2	5		01	7b;		2		2			1	20.00	20.00	2	
H5216	124	0	1	04	01	H5216_124_0	2	6		01	9a;		2		2			1	250.00	250.00	2	
H5216	124	0	1	04	01	H5216_124_0	2	7		01	5;7d;7e;7f;7h;8b1;9c;16b;18a;		2		2			1	30.00	250.00	2	
H5216	124	0	1	04	01	H5216_124_0	2	8		10		18b;	2		2			1	399.00	699.00	2	
H5216	124	0	1	04	01	H5216_124_0	2	9		01	7a;7g;8b3;		2		2			1	5.00	90.00	2	
H5216	125	0	1	04	01	H5216_125_0	3	1		11	6;9d;14a;14d;17b;	9d;14b;17a;	2		2			1	0.00	0.00	2	
H5216	125	0	1	04	01	H5216_125_0	3	2		01	11a;		2		1	17	17	2			2	
H5216	125	0	1	04	01	H5216_125_0	3	3		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;10a;11b;12;15;16b;17a;18a;		2		1	20	20	2			2	
H5216	125	0	1	04	01	H5216_125_0	3	4		01	8a2;11c;14e;		2		1	20	20	1	0.00	0.00	2	
H5216	125	0	1	04	01	H5216_125_0	3	5		10		13c;14c;	2		1	50	50	2			2	
H5216	125	0	1	04	01	H5216_125_0	3	6		10		13b;	1	15.00	1	50	50	2			2	
H5216	126	0	1	04	01	H5216_126_0	3	1		11	6;9d;14a;14d;14e;17b;	9d;14b;	2		2			1	0.00	0.00	2	
H5216	126	0	1	04	01	H5216_126_0	3	10		01	11a;11b;12;15;		2		1	20	20	2			2	
H5216	126	0	1	04	01	H5216_126_0	3	11		01	11c;		2		1	20	20	1	10.00	10.00	2	
H5216	126	0	1	04	01	H5216_126_0	3	12		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	126	0	1	04	01	H5216_126_0	3	13		01	8b2;		2		1	20	20	1	30.00	30.00	2	
H5216	126	0	1	04	01	H5216_126_0	3	14		10		13c;14c;	2		1	50	50	2			2	
H5216	126	0	1	04	01	H5216_126_0	3	15		10		13b;	1	30.00	1	50	50	2			2	
H5216	126	0	1	04	01	H5216_126_0	3	2		01	8a1;8a2;17a;		2		2			1	0.00	90.00	2	
H5216	126	0	1	04	01	H5216_126_0	3	3		01	3-1;3-2;3-3;7c;7i;		2		2			1	10.00	40.00	2	
H5216	126	0	1	04	01	H5216_126_0	3	4		01	9b;		2		2			1	100.00	100.00	2	
H5216	126	0	1	04	01	H5216_126_0	3	5		01	9a;		2		2			1	150.00	150.00	2	
H5216	126	0	1	04	01	H5216_126_0	3	6		01	7b;		2		2			1	20.00	20.00	2	
H5216	126	0	1	04	01	H5216_126_0	3	7		01	8b1;9c;		2		2			1	30.00	150.00	2	
H5216	126	0	1	04	01	H5216_126_0	3	8		01	5;7d;7e;7f;7h;16b;18a;		2		2			1	30.00	30.00	2	
H5216	126	0	1	04	01	H5216_126_0	3	9		01	7a;7g;8b3;		2		2			1	5.00	100.00	2	
H5216	127	0	1	04	01	H5216_127_0	2	1		11	9d;17b;	9d;	2		2			1	0.00	0.00	2	
H5216	127	0	1	04	01	H5216_127_0	2	2		01	12;		2		1	20	20	2			2	
H5216	127	0	1	04	01	H5216_127_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	127	0	1	04	01	H5216_127_0	2	4		01	15;		2		1	20	35	2			2	
H5216	127	0	1	04	01	H5216_127_0	2	5		01	11a;		2		1	25	25	2			2	
H5216	127	0	1	04	01	H5216_127_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	14b;	2		1	35	35	2			2	
H5216	127	0	1	04	01	H5216_127_0	2	7		01	14a;		2		1	35	35	1	0.00	0.00	2	
H5216	127	0	1	04	01	H5216_127_0	2	8		10		13c;14c;	2		1	50	50	2			2	
H5216	127	0	1	04	01	H5216_127_0	2	9		10		13b;	1	30.00	1	50	50	2			2	
H5216	128	0	1	04	01	H5216_128_0	2	1		11	9d;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5216	128	0	1	04	01	H5216_128_0	2	2		01	6;11a;11b;11c;12;		2		1	20	20	2			2	
H5216	128	0	1	04	01	H5216_128_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	128	0	1	04	01	H5216_128_0	2	4		01	15;		2		1	20	30	2			2	
H5216	128	0	1	04	01	H5216_128_0	2	5		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;17b;18a;	14b;	2		1	30	30	2			2	
H5216	128	0	1	04	01	H5216_128_0	2	6		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	128	0	1	04	01	H5216_128_0	2	7		10		13c;14c;	2		1	50	50	2			2	
H5216	128	0	1	04	01	H5216_128_0	2	8		10		13b;	1	25.00	1	50	50	2			2	
H5216	129	0	1	04	01	H5216_129_0	1	1		11	9d;17b;	9d;	2		2			1	0.00	0.00	2	
H5216	129	0	1	04	01	H5216_129_0	1	2		01	12;		2		1	20	20	2			2	
H5216	129	0	1	04	01	H5216_129_0	1	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	129	0	1	04	01	H5216_129_0	1	4		01	15;		2		1	20	35	2			2	
H5216	129	0	1	04	01	H5216_129_0	1	5		01	11a;		2		1	25	25	2			2	
H5216	129	0	1	04	01	H5216_129_0	1	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	14b;	2		1	35	35	2			2	
H5216	129	0	1	04	01	H5216_129_0	1	7		01	14a;		2		1	35	35	1	0.00	0.00	2	
H5216	129	0	1	04	01	H5216_129_0	1	8		10		13c;14c;	2		1	50	50	2			2	
H5216	129	0	1	04	01	H5216_129_0	1	9		10		13b;	1	30.00	1	50	50	2			2	
H5216	131	0	1	04	01	H5216_131_0	4	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	131	0	1	04	01	H5216_131_0	4	2		10		18b;	2		2			1	599.00	899.00	2	
H5216	131	0	1	04	01	H5216_131_0	4	3		01	12;		2		1	20	20	2			2	
H5216	131	0	1	04	01	H5216_131_0	4	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	131	0	1	04	01	H5216_131_0	4	5		01	11a;		2		1	30	30	2			2	
H5216	131	0	1	04	01	H5216_131_0	4	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	14b;	2		1	45	45	2			2	
H5216	131	0	1	04	01	H5216_131_0	4	7		01	14a;		2		1	45	50	1	0.00	0.00	2	
H5216	131	0	1	04	01	H5216_131_0	4	8		10		13a;13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	131	0	1	04	01	H5216_131_0	4	9		10		13b;	1	30.00	1	50	50	2			2	
H5216	132	0	1	04	01	H5216_132_0	4	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	132	0	1	04	01	H5216_132_0	4	2		10		18b;	2		2			1	399.00	699.00	2	
H5216	132	0	1	04	01	H5216_132_0	4	3		01	12;		2		1	20	20	2			2	
H5216	132	0	1	04	01	H5216_132_0	4	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	132	0	1	04	01	H5216_132_0	4	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	132	0	1	04	01	H5216_132_0	4	6		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	132	0	1	04	01	H5216_132_0	4	7		10		13a;13c;14c;16a;	2		1	50	50	2			2	
H5216	132	0	1	04	01	H5216_132_0	4	8		10		13b;	1	50.00	1	50	50	2			2	
H5216	133	0	1	04	01	H5216_133_0	2	1		11	9d;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5216	133	0	1	04	01	H5216_133_0	2	2		01	11a;		2		1	13	13	2			2	
H5216	133	0	1	04	01	H5216_133_0	2	3		01	10a;12;		2		1	20	20	2			2	
H5216	133	0	1	04	01	H5216_133_0	2	4		10		18a;18b;	2		1	25	25	2			2	
H5216	133	0	1	04	01	H5216_133_0	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	10b;13c;14b;14c;16a;16b;	2		1	50	50	2			2	
H5216	133	0	1	04	01	H5216_133_0	2	6		10		13b;	1	50.00	1	50	50	2			2	
H5216	133	0	1	04	01	H5216_133_0	2	7		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	135	0	1	04	01	H5216_135_0	2	1		11	9d;17b;	9d;17a;18a;	2		2			1	0.00	0.00	2	
H5216	135	0	1	04	01	H5216_135_0	2	10		10		13b;	1	25.00	1	50	50	2			2	
H5216	135	0	1	04	01	H5216_135_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	135	0	1	04	01	H5216_135_0	2	3		01	12;		2		1	20	20	2			2	
H5216	135	0	1	04	01	H5216_135_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	135	0	1	04	01	H5216_135_0	2	5		01	11a;		2		1	22	22	2			2	
H5216	135	0	1	04	01	H5216_135_0	2	6		01	11c;		2		1	25	25	2			2	
H5216	135	0	1	04	01	H5216_135_0	2	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	135	0	1	04	01	H5216_135_0	2	8		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	135	0	1	04	01	H5216_135_0	2	9		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	136	0	1	04	01	H5216_136_0	2	1		11	9d;17b;	9d;17a;18a;	2		2			1	0.00	0.00	2	
H5216	136	0	1	04	01	H5216_136_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	136	0	1	04	01	H5216_136_0	2	3		01	11a;12;		2		1	20	20	2			2	
H5216	136	0	1	04	01	H5216_136_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	136	0	1	04	01	H5216_136_0	2	5		01	11c;		2		1	20	30	2			2	
H5216	136	0	1	04	01	H5216_136_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5216	136	0	1	04	01	H5216_136_0	2	7		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5216	136	0	1	04	01	H5216_136_0	2	8		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5216	136	0	1	04	01	H5216_136_0	2	9		10		13b;	1	25.00	1	50	50	2			2	
H5216	137	0	1	04	01	H5216_137_0	5	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	137	0	1	04	01	H5216_137_0	5	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	137	0	1	04	01	H5216_137_0	5	3		01	6;10a;11a;12;		2		1	20	20	2			2	
H5216	137	0	1	04	01	H5216_137_0	5	4		01	14a;		2		1	30	40	1	0.00	0.00	2	
H5216	137	0	1	04	01	H5216_137_0	5	5		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	14b;	2		1	40	40	2			2	
H5216	137	0	1	04	01	H5216_137_0	5	6		10		13c;14c;	2		1	50	50	2			2	
H5216	137	0	1	04	01	H5216_137_0	5	7		10		13b;	1	50.00	1	50	50	2			2	
H5216	138	0	1	04	01	H5216_138_0	5	1		11	9d;17b;	9d;	2		2			1	0.00	0.00	2	
H5216	138	0	1	04	01	H5216_138_0	5	2		01	8b2;11a;12;		2		1	20	20	2			2	
H5216	138	0	1	04	01	H5216_138_0	5	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	138	0	1	04	01	H5216_138_0	5	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13c;14b;14c;	2		1	50	50	2			2	
H5216	138	0	1	04	01	H5216_138_0	5	5		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5216	139	0	1	04	01	H5216_139_0	4	1		11	6;9d;	9d;17a;18a;	2		2			1	0.00	0.00	2	
H5216	139	0	1	04	01	H5216_139_0	4	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	139	0	1	04	01	H5216_139_0	4	3		01	11a;		2		1	18	18	2			2	
H5216	139	0	1	04	01	H5216_139_0	4	4		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;10a;11b;12;14d;14e;15;16b;17a;17b;18a;	14b;	2		1	20	20	2			2	
H5216	139	0	1	04	01	H5216_139_0	4	5		01	11c;14a;		2		1	20	20	1	0.00	0.00	2	
H5216	139	0	1	04	01	H5216_139_0	4	6		10		13c;14c;16a;	2		1	50	50	2			2	
H5216	139	0	1	04	01	H5216_139_0	4	7		10		13b;	1	30.00	1	50	50	2			2	
H5216	140	0	1	04	01	H5216_140_0	2	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5216	140	0	1	04	01	H5216_140_0	2	10		10		13b;	1	25.00	1	50	50	2			2	
H5216	140	0	1	04	01	H5216_140_0	2	11		10		16b;	2		1	50	55	2			2	
H5216	140	0	1	04	01	H5216_140_0	2	2		01	11a;		2		1	15	15	2			2	
H5216	140	0	1	04	01	H5216_140_0	2	3		01	12;		2		1	20	20	2			2	
H5216	140	0	1	04	01	H5216_140_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	140	0	1	04	01	H5216_140_0	2	5		01	15;		2		1	20	40	2			2	
H5216	140	0	1	04	01	H5216_140_0	2	6		10		18a;18b;	2		1	25	25	2			2	
H5216	140	0	1	04	01	H5216_140_0	2	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	14b;	2		1	40	40	2			2	
H5216	140	0	1	04	01	H5216_140_0	2	8		01	14a;		2		1	40	40	1	0.00	0.00	2	
H5216	140	0	1	04	01	H5216_140_0	2	9		10		13c;14c;16a;	2		1	50	50	2			2	
H5216	141	0	1	04	01	H5216_141_0	3	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5216	141	0	1	04	01	H5216_141_0	3	2		10		18b;	2		2			1	699.00	999.00	2	
H5216	141	0	1	04	01	H5216_141_0	3	3		01	12;		2		1	20	20	2			2	
H5216	141	0	1	04	01	H5216_141_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5216	141	0	1	04	01	H5216_141_0	3	5		01	11a;		2		1	25	25	2			2	
H5216	141	0	1	04	01	H5216_141_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	14b;	2		1	40	40	2			2	
H5216	141	0	1	04	01	H5216_141_0	3	7		01	14a;		2		1	40	40	1	0.00	0.00	2	
H5216	141	0	1	04	01	H5216_141_0	3	8		10		13c;14c;16a;	2		1	50	50	2			2	
H5216	805	0	1	04	01	H5216_805_0	4	1		01	6;14a;		2		1	0	0	2			2	
H5216	805	0	1	04	01	H5216_805_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5216	806	0	1	04	01	H5216_806_0	4	1		01	6;14a;		2		1	0	0	2			2	
H5216	806	0	1	04	01	H5216_806_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5216	807	0	1	04	01	H5216_807_0	4	1		01	6;14a;		2		1	0	0	2			2	
H5216	807	0	1	04	01	H5216_807_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5216	808	0	2	04	01	H5216_808_0	4	1		01	6;14a;		2		1	0	0	2			2	
H5216	808	0	2	04	01	H5216_808_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5216	809	0	2	04	01	H5216_809_0	5	1		01	6;14a;		2		1	0	0	2			2	
H5216	809	0	2	04	01	H5216_809_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5216	810	0	2	04	01	H5216_810_0	5	1		01	6;14a;		2		1	0	0	2			2	
H5216	810	0	2	04	01	H5216_810_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5434	002	0	1	04	01	H5434_002_0	13	1	40%	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;14a;14d;14e;16b;17a;17b;18a;	9d;18a;	2		1	40	40	2			2	
H5434	002	0	1	04	01	H5434_002_0	13	2	50% DME & Part B Drugs	01	6;11a;15;		2		1	50	50	2			2	
H5434	002	0	1	04	01	H5434_002_0	13	3	Ambulance	01	10a;		2		2			1	150.00	150.00	2	
H5434	002	0	1	04	01	H5434_002_0	13	4	20%	01	11c;12;		2		1	20	20	2			2	
H5434	002	0	1	04	01	H5434_002_0	13	5	Fitness and Pre-Diabetic Program	10		14c;	2		2			2			2	
H5434	002	0	1	04	01	H5434_002_0	13	6	50%  Dental	10		16a;16b;	2		1	50	50	2			2	
H5434	002	0	1	04	01	H5434_002_0	13	7	Eyewear	10		17b;	2		1	100	100	2			2	
H5434	002	0	1	04	01	H5434_002_0	13	8	Eye exam	10		17a;	2		1	100	100	2			2	
H5434	002	0	1	04	01	H5434_002_0	13	9	Hearing Aides	10		18b;	2		2			1	699.00	999.00	2	
H5434	801	0	1	04	01	H5434_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
H5434	801	0	1	04	01	H5434_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5434	802	0	1	04	01	H5434_802_0	2	1		01	6;14a;		2		1	0	0	2			2	
H5434	802	0	1	04	01	H5434_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5439	010	0	1	04	01	H5439_010_0	3	1	Group $20	01	7a;8b3;		2		2			1	20.00	20.00	2	
H5439	010	0	1	04	01	H5439_010_0	3	10	Group $175	01	9b;		2		2			1	175.00	175.00	2	
H5439	010	0	1	04	01	H5439_010_0	3	11	Group $0	11	5;8a2;9d;14a;14d;14e;17b;	9d;14b;17b;	2		2			1	0.00	0.00	2	
H5439	010	0	1	04	01	H5439_010_0	3	12	Group 0% - 20%	01	8a1;		2		1	0	20	2			2	
H5439	010	0	1	04	01	H5439_010_0	3	13	Group $0 - $15 with $500 Ben Max	10		7b;13a;14c;	1	500.00	2			1	0.00	15.00	2	
H5439	010	0	1	04	01	H5439_010_0	3	2	Group 30%	01	6;		2		1	30	30	2			2	
H5439	010	0	1	04	01	H5439_010_0	3	3	Group $40	11	3-1;3-2;3-3;7c;7d;7e;7f;7h;7i;9c;16b;17a;18a;	17a;	2		2			1	40.00	40.00	2	
H5439	010	0	1	04	01	H5439_010_0	3	4	Group 20%	01	8b1;8b2;11a;11b;12;15;		2		1	20	20	2			2	
H5439	010	0	1	04	01	H5439_010_0	3	5	Group $20 - $40	01	7g;		2		2			1	20.00	40.00	2	
H5439	010	0	1	04	01	H5439_010_0	3	6	Group $0 or 20%	01	11c;		2		1	20	20	1	0.00	0.00	2	
H5439	010	0	1	04	01	H5439_010_0	3	7	Group $100	01	10a;		2		2			1	100.00	100.00	2	
H5439	010	0	1	04	01	H5439_010_0	3	8	Group $15	01	7b;		2		2			1	15.00	15.00	2	
H5439	010	0	1	04	01	H5439_010_0	3	9	Group $200	01	9a;		2		2			1	200.00	200.00	2	
H5439	011	0	1	04	01	H5439_011_0	4	1	Group $20	01	7a;8a2;8b3;		2		2			1	20.00	20.00	2	
H5439	011	0	1	04	01	H5439_011_0	4	10	Group $0	11	5;9d;14a;14d;14e;17b;	9d;14b;17b;	2		2			1	0.00	0.00	2	
H5439	011	0	1	04	01	H5439_011_0	4	11	Group 0% - 19%	01	8a1;		2		1	0	19	2			2	
H5439	011	0	1	04	01	H5439_011_0	4	12	Group $0 or 19%	01	11c;		2		1	19	19	1	0.00	0.00	2	
H5439	011	0	1	04	01	H5439_011_0	4	13	Group $295	01	10a;		2		2			1	295.00	295.00	2	
H5439	011	0	1	04	01	H5439_011_0	4	14	Group $20 - $40	01	7g;		2		2			1	20.00	40.00	2	
H5439	011	0	1	04	01	H5439_011_0	4	2	Group 30%	01	6;		2		1	30	30	2			2	
H5439	011	0	1	04	01	H5439_011_0	4	3	Group $0 - $15 with $500 Ben Max	10		7b;13a;14c;	1	500.00	2			1	0.00	15.00	2	
H5439	011	0	1	04	01	H5439_011_0	4	4	Group 19%	01	8b1;8b2;11a;11b;15;		2		1	19	19	2			2	
H5439	011	0	1	04	01	H5439_011_0	4	5	Group 20%	01	12;		2		1	20	20	2			2	
H5439	011	0	1	04	01	H5439_011_0	4	6	Group $40	11	3-1;3-2;3-3;7c;7d;7e;7f;7h;7i;9c;16b;17a;18a;	17a;	2		2			1	40.00	40.00	2	
H5439	011	0	1	04	01	H5439_011_0	4	7	Group $225	01	9b;		2		2			1	225.00	225.00	2	
H5439	011	0	1	04	01	H5439_011_0	4	8	Group $15	01	7b;		2		2			1	15.00	15.00	2	
H5439	011	0	1	04	01	H5439_011_0	4	9	Group $250	01	9a;		2		2			1	250.00	250.00	2	
H5439	012	0	1	04	01	H5439_012_0	3	1	Group $20	01	7a;8b3;		2		2			1	20.00	20.00	2	
H5439	012	0	1	04	01	H5439_012_0	3	10	Group $175	01	9b;		2		2			1	175.00	175.00	2	
H5439	012	0	1	04	01	H5439_012_0	3	11	Group $0	11	5;8a2;9d;14a;14d;14e;17b;	9d;14b;17b;	2		2			1	0.00	0.00	2	
H5439	012	0	1	04	01	H5439_012_0	3	12	Group 0% - 20%	01	8a1;		2		1	0	20	2			2	
H5439	012	0	1	04	01	H5439_012_0	3	13	Group $0 - $15 with $500 Ben Max	10		7b;13a;14c;	1	500.00	2			1	0.00	15.00	2	
H5439	012	0	1	04	01	H5439_012_0	3	2	Group 30%	01	6;		2		1	30	30	2			2	
H5439	012	0	1	04	01	H5439_012_0	3	3	Group $40	11	3-1;3-2;3-3;7c;7d;7e;7f;7h;7i;9c;16b;17a;18a;	17a;	2		2			1	40.00	40.00	2	
H5439	012	0	1	04	01	H5439_012_0	3	4	Group 20%	01	8b1;8b2;11a;11b;12;15;		2		1	20	20	2			2	
H5439	012	0	1	04	01	H5439_012_0	3	5	Group $20 - $40	01	7g;		2		2			1	20.00	40.00	2	
H5439	012	0	1	04	01	H5439_012_0	3	6	Group $0 or 20%	01	11c;		2		1	20	20	1	0.00	0.00	2	
H5439	012	0	1	04	01	H5439_012_0	3	7	Group $100	01	10a;		2		2			1	100.00	100.00	2	
H5439	012	0	1	04	01	H5439_012_0	3	8	Group $15	01	7b;		2		2			1	15.00	15.00	2	
H5439	012	0	1	04	01	H5439_012_0	3	9	Group $200	01	9a;		2		2			1	200.00	200.00	2	
H5439	013	0	1	04	01	H5439_013_0	4	1	Group $20	01	7a;8a2;8b3;		2		2			1	20.00	20.00	2	
H5439	013	0	1	04	01	H5439_013_0	4	10	Group $0	11	5;9d;14a;14d;14e;17b;	9d;14b;17b;	2		2			1	0.00	0.00	2	
H5439	013	0	1	04	01	H5439_013_0	4	11	Group 0% - 19%	01	8a1;		2		1	0	19	2			2	
H5439	013	0	1	04	01	H5439_013_0	4	12	Group $0 or 19%	01	11c;		2		1	19	19	1	0.00	0.00	2	
H5439	013	0	1	04	01	H5439_013_0	4	13	Group $200	01	10a;		2		2			1	200.00	200.00	2	
H5439	013	0	1	04	01	H5439_013_0	4	14	Group $20 - $40	01	7g;		2		2			1	20.00	40.00	2	
H5439	013	0	1	04	01	H5439_013_0	4	2	Group 30%	01	6;		2		1	30	30	2			2	
H5439	013	0	1	04	01	H5439_013_0	4	3	Group $0 - $15 with $500 Ben Max	10		7b;13a;14c;	1	500.00	2			1	0.00	15.00	2	
H5439	013	0	1	04	01	H5439_013_0	4	4	Group 19%	01	8b1;8b2;11a;11b;15;		2		1	19	19	2			2	
H5439	013	0	1	04	01	H5439_013_0	4	5	Group 20%	01	12;		2		1	20	20	2			2	
H5439	013	0	1	04	01	H5439_013_0	4	6	Group $40	11	3-1;3-2;3-3;7c;7d;7e;7f;7h;7i;9c;16b;17a;18a;	17a;	2		2			1	40.00	40.00	2	
H5439	013	0	1	04	01	H5439_013_0	4	7	Group $225	01	9b;		2		2			1	225.00	225.00	2	
H5439	013	0	1	04	01	H5439_013_0	4	8	Group $15	01	7b;		2		2			1	15.00	15.00	2	
H5439	013	0	1	04	01	H5439_013_0	4	9	Group $250	01	9a;		2		2			1	250.00	250.00	2	
H5439	014	1	1	04	01	H5439_014_1	5	1	Group $20	01	7b;8a2;8b3;		2		2			1	20.00	20.00	2	
H5439	014	1	1	04	01	H5439_014_1	5	10	Group $30 - $50	01	7g;		2		2			1	30.00	50.00	2	
H5439	014	1	1	04	01	H5439_014_1	5	2	Group 30%	01	6;		2		1	30	30	2			2	
H5439	014	1	1	04	01	H5439_014_1	5	3	Group $50	01	3-1;3-2;3-3;7c;7d;7e;7f;7h;7i;9c;16b;17a;18a;		2		2			1	50.00	50.00	2	
H5439	014	1	1	04	01	H5439_014_1	5	4	Group 20%	01	8b1;8b2;9a;9b;11a;11b;12;15;17b;		2		1	20	20	2			2	
H5439	014	1	1	04	01	H5439_014_1	5	5	Group $0 or 20%	01	11c;		2		1	20	20	1	0.00	0.00	2	
H5439	014	1	1	04	01	H5439_014_1	5	6	Group $380	01	10a;		2		2			1	380.00	380.00	2	
H5439	014	1	1	04	01	H5439_014_1	5	7	Group $0	11	5;9d;14a;14d;14e;	9d;14b;14c;	2		2			1	0.00	0.00	2	
H5439	014	1	1	04	01	H5439_014_1	5	8	Group $30	01	7a;		2		2			1	30.00	30.00	2	
H5439	014	1	1	04	01	H5439_014_1	5	9	Group 0% - 20%	01	8a1;		2		1	0	20	2			2	
H5439	014	2	1	04	01	H5439_014_2	4	1	Group $20	01	7b;		2		2			1	20.00	20.00	2	
H5439	014	2	1	04	01	H5439_014_2	4	10	Group $0	11	5;9d;14a;14d;14e;	9d;14b;14c;	2		2			1	0.00	0.00	2	
H5439	014	2	1	04	01	H5439_014_2	4	11	Group $30 - $50	01	7g;		2		2			1	30.00	50.00	2	
H5439	014	2	1	04	01	H5439_014_2	4	2	Group $30	01	7a;		2		2			1	30.00	30.00	2	
H5439	014	2	1	04	01	H5439_014_2	4	3	Group $50	01	3-1;3-2;3-3;7c;7d;7e;7f;7h;7i;9c;16b;17a;18a;		2		2			1	50.00	50.00	2	
H5439	014	2	1	04	01	H5439_014_2	4	4	Group 20%	01	17b;		2		1	20	20	2			2	
H5439	014	2	1	04	01	H5439_014_2	4	5	Group $0 or 30%	01	11c;		2		1	30	30	1	0.00	0.00	2	
H5439	014	2	1	04	01	H5439_014_2	4	6	Group $325	01	10a;		2		2			1	325.00	325.00	2	
H5439	014	2	1	04	01	H5439_014_2	4	7	Group $25	01	8a2;8b3;		2		2			1	25.00	25.00	2	
H5439	014	2	1	04	01	H5439_014_2	4	8	Group 30%	01	6;8b1;8b2;9a;9b;11a;11b;12;15;		2		1	30	30	2			2	
H5439	014	2	1	04	01	H5439_014_2	4	9	Group 0% - 30%	01	8a1;		2		1	0	30	2			2	
H5439	014	3	1	04	01	H5439_014_3	4	1	Group $20	01	7b;8a2;8b3;		2		2			1	20.00	20.00	2	
H5439	014	3	1	04	01	H5439_014_3	4	10	Group $325	01	9b;		2		2			1	325.00	325.00	2	
H5439	014	3	1	04	01	H5439_014_3	4	11	Group $40	01	7a;		2		2			1	40.00	40.00	2	
H5439	014	3	1	04	01	H5439_014_3	4	12	Group $40 - $50	01	7g;		2		2			1	40.00	50.00	2	
H5439	014	3	1	04	01	H5439_014_3	4	2	Group 30%	01	6;		2		1	30	30	2			2	
H5439	014	3	1	04	01	H5439_014_3	4	3	Group $50	01	3-1;3-2;3-3;7c;7d;7e;7f;7h;7i;9c;16b;17a;18a;		2		2			1	50.00	50.00	2	
H5439	014	3	1	04	01	H5439_014_3	4	4	Group 20%	01	8b1;8b2;11a;11b;12;15;17b;		2		1	20	20	2			2	
H5439	014	3	1	04	01	H5439_014_3	4	5	Group $0 or 20%	01	11c;		2		1	20	20	1	0.00	0.00	2	
H5439	014	3	1	04	01	H5439_014_3	4	6	Group $325	01	10a;		2		2			1	325.00	325.00	2	
H5439	014	3	1	04	01	H5439_014_3	4	7	Group $0	11	5;9d;14a;14d;14e;	9d;14b;14c;	2		2			1	0.00	0.00	2	
H5439	014	3	1	04	01	H5439_014_3	4	8	Group $500	01	9a;		2		2			1	500.00	500.00	2	
H5439	014	3	1	04	01	H5439_014_3	4	9	Group 0% - 20%	01	8a1;		2		1	0	20	2			2	
H5439	014	4	1	04	01	H5439_014_4	4	1	Group $20	01	7b;8a2;8b3;		2		2			1	20.00	20.00	2	
H5439	014	4	1	04	01	H5439_014_4	4	10	Group 25%	01	8b1;8b2;11a;11b;15;		2		1	25	25	2			2	
H5439	014	4	1	04	01	H5439_014_4	4	11	Group $30 - $50	01	7g;		2		2			1	30.00	50.00	2	
H5439	014	4	1	04	01	H5439_014_4	4	12	Group $30	01	7a;		2		2			1	30.00	30.00	2	
H5439	014	4	1	04	01	H5439_014_4	4	13	Group $310	01	9b;		2		2			1	310.00	310.00	2	
H5439	014	4	1	04	01	H5439_014_4	4	2	Group 30%	01	6;		2		1	30	30	2			2	
H5439	014	4	1	04	01	H5439_014_4	4	3	Group $50	01	3-1;3-2;3-3;7c;7d;7e;7f;7h;7i;9c;16b;17a;18a;		2		2			1	50.00	50.00	2	
H5439	014	4	1	04	01	H5439_014_4	4	4	Group 20%	01	12;17b;		2		1	20	20	2			2	
H5439	014	4	1	04	01	H5439_014_4	4	5	Group $0 or 25%	01	11c;		2		1	25	25	1	0.00	0.00	2	
H5439	014	4	1	04	01	H5439_014_4	4	6	Group $380	01	10a;		2		2			1	380.00	380.00	2	
H5439	014	4	1	04	01	H5439_014_4	4	7	Group $0	11	5;9d;14a;14d;14e;	9d;14b;14c;	2		2			1	0.00	0.00	2	
H5439	014	4	1	04	01	H5439_014_4	4	8	Group $350	01	9a;		2		2			1	350.00	350.00	2	
H5439	014	4	1	04	01	H5439_014_4	4	9	Group 0% - 25%	01	8a1;		2		1	0	25	2			2	
H5439	015	0	1	04	01	H5439_015_0	4	1	Group $20	01	7b;8a2;8b3;		2		2			1	20.00	20.00	2	
H5439	015	0	1	04	01	H5439_015_0	4	10	Group $30	01	7a;		2		2			1	30.00	30.00	2	
H5439	015	0	1	04	01	H5439_015_0	4	11	Group $30 - $50	01	7g;		2		2			1	30.00	50.00	2	
H5439	015	0	1	04	01	H5439_015_0	4	12	Group $285	01	9b;		2		2			1	285.00	285.00	2	
H5439	015	0	1	04	01	H5439_015_0	4	2	Group 30%	01	6;		2		1	30	30	2			2	
H5439	015	0	1	04	01	H5439_015_0	4	3	Group $50	11	3-1;3-2;3-3;7c;7d;7e;7f;7h;7i;9c;16b;17a;18a;	17a;	2		2			1	50.00	50.00	2	
H5439	015	0	1	04	01	H5439_015_0	4	4	Group 20%	11	8b1;8b2;11a;11b;12;15;17b;	17b;	2		1	20	20	2			2	
H5439	015	0	1	04	01	H5439_015_0	4	5	Group $0 or 20%	01	11c;		2		1	20	20	1	0.00	0.00	2	
H5439	015	0	1	04	01	H5439_015_0	4	6	Group $380	01	10a;		2		2			1	380.00	380.00	2	
H5439	015	0	1	04	01	H5439_015_0	4	7	Group $0	11	5;9d;14a;14d;14e;	9d;14b;14c;	2		2			1	0.00	0.00	2	
H5439	015	0	1	04	01	H5439_015_0	4	8	Group $335	01	9a;		2		2			1	335.00	335.00	2	
H5439	015	0	1	04	01	H5439_015_0	4	9	Group 0% - 20%	01	8a1;		2		1	0	20	2			2	
H5439	016	1	1	04	01	H5439_016_1	4	1	Group $20	01	7b;8a2;8b3;		2		2			1	20.00	20.00	2	
H5439	016	1	1	04	01	H5439_016_1	4	10	Group $275	01	9b;		2		2			1	275.00	275.00	2	
H5439	016	1	1	04	01	H5439_016_1	4	11	Group $30 - $50	01	7g;		2		2			1	30.00	50.00	2	
H5439	016	1	1	04	01	H5439_016_1	4	12	Group $30	01	7a;		2		2			1	30.00	30.00	2	
H5439	016	1	1	04	01	H5439_016_1	4	2	Group 30%	01	6;		2		1	30	30	2			2	
H5439	016	1	1	04	01	H5439_016_1	4	3	Group $50	11	3-1;3-2;3-3;7c;7d;7e;7f;7h;7i;9c;16b;17a;18a;	17a;	2		2			1	50.00	50.00	2	
H5439	016	1	1	04	01	H5439_016_1	4	4	Group 20%	01	8b1;8b2;11a;11b;12;15;		2		1	20	20	2			2	
H5439	016	1	1	04	01	H5439_016_1	4	5	Group $0 or 20%	01	11c;		2		1	20	20	1	0.00	0.00	2	
H5439	016	1	1	04	01	H5439_016_1	4	6	Group $250	01	10a;		2		2			1	250.00	250.00	2	
H5439	016	1	1	04	01	H5439_016_1	4	7	Group $0	11	5;9d;14a;14d;14e;17b;	9d;14b;14c;17b;	2		2			1	0.00	0.00	2	
H5439	016	1	1	04	01	H5439_016_1	4	8	Group $325	01	9a;		2		2			1	325.00	325.00	2	
H5439	016	1	1	04	01	H5439_016_1	4	9	Group 0% - 20%	01	8a1;		2		1	0	20	2			2	
H5439	016	2	1	04	01	H5439_016_2	4	1	Group $20	01	7b;8a2;8b3;		2		2			1	20.00	20.00	2	
H5439	016	2	1	04	01	H5439_016_2	4	10	Group $275	01	9b;		2		2			1	275.00	275.00	2	
H5439	016	2	1	04	01	H5439_016_2	4	11	Group $30 - $50	01	7g;		2		2			1	30.00	50.00	2	
H5439	016	2	1	04	01	H5439_016_2	4	12	Group $30	01	7a;		2		2			1	30.00	30.00	2	
H5439	016	2	1	04	01	H5439_016_2	4	2	Group 30%	01	6;		2		1	30	30	2			2	
H5439	016	2	1	04	01	H5439_016_2	4	3	Group $50	11	3-1;3-2;3-3;7c;7d;7e;7f;7h;7i;9c;16b;17a;18a;	17a;	2		2			1	50.00	50.00	2	
H5439	016	2	1	04	01	H5439_016_2	4	4	Group 20%	01	8b1;8b2;11a;11b;12;15;		2		1	20	20	2			2	
H5439	016	2	1	04	01	H5439_016_2	4	5	Group $0 or 20%	01	11c;		2		1	20	20	1	0.00	0.00	2	
H5439	016	2	1	04	01	H5439_016_2	4	6	Group $275	01	10a;		2		2			1	275.00	275.00	2	
H5439	016	2	1	04	01	H5439_016_2	4	7	Group $0	11	5;9d;14a;14d;14e;17b;	9d;14b;14c;17b;	2		2			1	0.00	0.00	2	
H5439	016	2	1	04	01	H5439_016_2	4	8	Group $325	01	9a;		2		2			1	325.00	325.00	2	
H5439	016	2	1	04	01	H5439_016_2	4	9	Group 0% - 20%	01	8a1;		2		1	0	20	2			2	
H5439	801	0	1	04	01	H5439_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
H5439	801	0	1	04	01	H5439_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5439	802	0	1	04	01	H5439_802_0	2	1		01	6;14a;		2		1	0	0	2			2	
H5439	802	0	1	04	01	H5439_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5439	803	0	1	04	01	H5439_803_0	2	1		01	6;14a;		2		1	0	0	2			2	
H5439	803	0	1	04	01	H5439_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5521	012	0	1	04	01	H5521_012_0	4	1	25%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	25	25	2			2	
H5521	012	0	1	04	01	H5521_012_0	4	2	$300	01	10a;		2		2			1	300.00	300.00	2	
H5521	012	0	1	04	01	H5521_012_0	4	3	20%	01	12;		2		1	20	20	2			2	
H5521	012	0	1	04	01	H5521_012_0	4	4	$0	11	14d;	14c;17b;18b;	2		2			1	0.00	0.00	2	
H5521	012	0	1	04	01	H5521_012_0	4	5	Preventive Dental	10		16a;	2		1	30	30	2			1	75.00
H5521	012	0	1	04	01	H5521_012_0	4	6	14a 0-25	01	14a;		2		1	0	25	2			2	
H5521	012	0	1	04	01	H5521_012_0	4	7	0-20%	01	11c;		2		1	0	20	2			2	
H5521	013	0	1	04	01	H5521_013_0	3	1	30% Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	30	30	2			2	
H5521	013	0	1	04	01	H5521_013_0	3	2	Ambulance	01	10a;		2		2			1	325.00	325.00	2	
H5521	013	0	1	04	01	H5521_013_0	3	3	20% Tier	01	12;		2		1	20	20	2			2	
H5521	013	0	1	04	01	H5521_013_0	3	4	0%-30% Tier	01	14a;		2		1	0	30	2			2	
H5521	013	0	1	04	01	H5521_013_0	3	5	0% tier	11	14d;	14c;	2		1	0	0	2			2	
H5521	013	0	1	04	01	H5521_013_0	3	6	$0	10		16a;17b;	2		2			1	0.00	0.00	2	
H5521	013	0	1	04	01	H5521_013_0	3	7	0-20%	01	11c;		2		1	0	20	2			2	
H5521	015	0	1	04	01	H5521_015_0	3	1	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	015	0	1	04	01	H5521_015_0	3	2	$350	01	10a;		2		2			1	350.00	350.00	2	
H5521	015	0	1	04	01	H5521_015_0	3	3	20%	01	12;		2		1	20	20	2			2	
H5521	015	0	1	04	01	H5521_015_0	3	4	$0	11	14d;	14c;	2		2			1	0.00	0.00	2	
H5521	015	0	1	04	01	H5521_015_0	3	5	0%-50%	01	14a;		2		1	0	50	2			2	
H5521	015	0	1	04	01	H5521_015_0	3	6	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	016	0	1	04	01	H5521_016_0	3	1	30% Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	30	30	2			2	
H5521	016	0	1	04	01	H5521_016_0	3	2	Ambulance	01	10a;		2		2			1	250.00	250.00	2	
H5521	016	0	1	04	01	H5521_016_0	3	3	20% Tier	01	12;		2		1	20	20	2			2	
H5521	016	0	1	04	01	H5521_016_0	3	4	0%-30%	01	14a;		2		1	0	30	2			2	
H5521	016	0	1	04	01	H5521_016_0	3	5	0% Tier	11	14d;	14c;16a;17b;	2		1	0	0	2			2	
H5521	016	0	1	04	01	H5521_016_0	3	6	OTC $25 Monthly	10		13b;	1	25.00	2			1	0.00	0.00	2	
H5521	016	0	1	04	01	H5521_016_0	3	7	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	020	0	1	04	01	H5521_020_0	3	1	50% Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	020	0	1	04	01	H5521_020_0	3	2	Ambulance	01	10a;		2		2			1	350.00	350.00	2	
H5521	020	0	1	04	01	H5521_020_0	3	3	ESRD	01	12;		2		1	20	20	2			2	
H5521	020	0	1	04	01	H5521_020_0	3	4	$0 Group	11	14d;	14c;16a;	2		2			1	0.00	0.00	2	
H5521	020	0	1	04	01	H5521_020_0	3	5	Medicare-covered Preventive Services	01	14a;		2		1	0	50	2			2	
H5521	020	0	1	04	01	H5521_020_0	3	6	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	022	0	1	04	01	H5521_022_0	3	1	40% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	40	40	2			2	
H5521	022	0	1	04	01	H5521_022_0	3	2	$275 copay	01	10a;		2		2			1	275.00	275.00	2	
H5521	022	0	1	04	01	H5521_022_0	3	3	Supplemental Benefits	11	14d;	14c;16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H5521	022	0	1	04	01	H5521_022_0	3	4	OON Range preventive	01	14a;		2		1	0	40	2			2	
H5521	022	0	1	04	01	H5521_022_0	3	5	Diabetic services	01	11c;		2		1	0	20	2			2	
H5521	027	0	1	04	01	H5521_027_0	5	1	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	027	0	1	04	01	H5521_027_0	5	2	$400	01	10a;		2		2			1	400.00	400.00	2	
H5521	027	0	1	04	01	H5521_027_0	5	3	20%	01	12;		2		1	20	20	2			2	
H5521	027	0	1	04	01	H5521_027_0	5	4	$0	11	14d;	14c;16a;	2		2			1	0.00	0.00	2	
H5521	027	0	1	04	01	H5521_027_0	5	5	25%	01	11a;		2		1	25	25	2			2	
H5521	027	0	1	04	01	H5521_027_0	5	6	25%-50%	01	11b;		2		1	25	50	2			2	
H5521	027	0	1	04	01	H5521_027_0	5	7	0%-50%	01	14a;		2		1	0	50	2			2	
H5521	027	0	1	04	01	H5521_027_0	5	8	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	033	0	1	04	01	H5521_033_0	6	1	Out of Nework $0 Copay	11	14a;14d;	14c;16a;16b;17b;	2		2			1	0.00	0.00	2	
H5521	033	0	1	04	01	H5521_033_0	6	2	Out of Network $300 Copay	01	10a;		2		2			1	300.00	300.00	2	
H5521	033	0	1	04	01	H5521_033_0	6	3	Out of Network $50 Copay	11	7a;7d;7f;7g;9d;16b;17a;18a;	9d;	2		2			1	50.00	50.00	2	
H5521	033	0	1	04	01	H5521_033_0	6	4	Out of Network 20% Coinsurance	01	12;		2		1	20	20	2			2	
H5521	033	0	1	04	01	H5521_033_0	6	5	Out of Network 50% Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14e;15;17b;	14b;17a;	2		1	50	50	2			2	
H5521	033	0	1	04	01	H5521_033_0	6	6	OON 0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	037	0	1	04	01	H5521_037_0	4	1	40% OON Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	40	40	2			2	
H5521	037	0	1	04	01	H5521_037_0	4	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	037	0	1	04	01	H5521_037_0	4	3	20%	01	12;		2		1	20	20	2			2	
H5521	037	0	1	04	01	H5521_037_0	4	4	$0 Copayment OON	10		14c;16a;	2		2			1	0.00	0.00	2	
H5521	037	0	1	04	01	H5521_037_0	4	5	0% to 40%	01	14a;		2		1	0	40	2			2	
H5521	037	0	1	04	01	H5521_037_0	4	6	0% OON	01	14d;		2		1	0	0	2			2	
H5521	037	0	1	04	01	H5521_037_0	4	7	0-20% OON	01	11c;		2		1	0	20	2			2	
H5521	040	0	1	04	01	H5521_040_0	5	1	30% OON Tier	11	3-1;3-2;3-3;5;6;7b;7c;7e;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14e;15;17b;	14b;17a;	2		1	30	30	2			2	
H5521	040	0	1	04	01	H5521_040_0	5	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	040	0	1	04	01	H5521_040_0	5	3	20% OON Tier	01	12;		2		1	20	20	2			2	
H5521	040	0	1	04	01	H5521_040_0	5	4	$0 OON	10		14c;	2		2			1	0.00	0.00	2	
H5521	040	0	1	04	01	H5521_040_0	5	5	0-30%	01	14a;		2		1	0	30	2			2	
H5521	040	0	1	04	01	H5521_040_0	5	6	$50 Copayment OON	11	7a;7d;7f;7g;9d;16b;17a;18a;	9d;18a;	2		2			1	50.00	50.00	2	
H5521	040	0	1	04	01	H5521_040_0	5	7	0% OON Tier	01	14d;		2		1	0	0	2			2	
H5521	040	0	1	04	01	H5521_040_0	5	8	0-20%	01	11c;		2		1	0	20	2			2	
H5521	053	0	1	04	01	H5521_053_0	6	1	40% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	40	40	2			2	
H5521	053	0	1	04	01	H5521_053_0	6	2	$300 copay	01	10a;		2		2			1	300.00	300.00	2	
H5521	053	0	1	04	01	H5521_053_0	6	3	20% coinsurance	01	12;		2		1	20	20	2			2	
H5521	053	0	1	04	01	H5521_053_0	6	4	$0 Supplemental Benefits	11	14d;	14c;	2		1	0	0	2			2	
H5521	053	0	1	04	01	H5521_053_0	6	5	0%-40%	01	14a;		2		1	0	40	2			2	
H5521	053	0	1	04	01	H5521_053_0	6	6	Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H5521	053	0	1	04	01	H5521_053_0	6	7	0% coins nmc	10		17b;	2		1	0	0	2			2	
H5521	055	0	1	04	01	H5521_055_0	4	1	40% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	40	40	2			2	
H5521	055	0	1	04	01	H5521_055_0	4	2	$325 copay	01	10a;		2		2			1	325.00	325.00	2	
H5521	055	0	1	04	01	H5521_055_0	4	3	OON Range preventive	01	14a;		2		1	0	40	2			2	
H5521	055	0	1	04	01	H5521_055_0	4	4	Supplemental Benefits	11	14d;	14c;16a;17b;	2		2			1	0.00	0.00	2	
H5521	055	0	1	04	01	H5521_055_0	4	5	Diabetic Services	01	11c;		2		1	0	20	2			2	
H5521	056	0	1	04	01	H5521_056_0	5	1	40% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	40	40	2			2	
H5521	056	0	1	04	01	H5521_056_0	5	2	$300 copay	01	10a;		2		2			1	300.00	300.00	2	
H5521	056	0	1	04	01	H5521_056_0	5	3	20% Coinsurance	01	12;		2		1	20	20	2			2	
H5521	056	0	1	04	01	H5521_056_0	5	4	0% Supplemental Benefits	11	14d;	14c;17b;	2		1	0	0	2			2	
H5521	056	0	1	04	01	H5521_056_0	5	5	0%-40% Range	01	14a;		2		1	0	40	2			2	
H5521	056	0	1	04	01	H5521_056_0	5	6	0%-20% Range	01	11c;		2		1	0	20	2			2	
H5521	057	0	1	04	01	H5521_057_0	3	1	40% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;12;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	40	40	2			2	
H5521	057	0	1	04	01	H5521_057_0	3	2	$275 copay	01	10a;		2		2			1	275.00	275.00	2	
H5521	057	0	1	04	01	H5521_057_0	3	3	Supplemental Benefits	11	14d;	14c;16a;17b;18b;	2		2			1	0.00	0.00	2	
H5521	057	0	1	04	01	H5521_057_0	3	4	OON Range	01	14a;		2		1	0	40	2			2	
H5521	057	0	1	04	01	H5521_057_0	3	5	Diabetic Services	01	11c;		2		1	0	20	2			2	
H5521	057	0	1	04	01	H5521_057_0	3	6	35% OON DME	01	11a;		2		1	35	35	2			2	
H5521	058	0	1	04	01	H5521_058_0	6	1	50% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	058	0	1	04	01	H5521_058_0	6	2	Ambulance - $375	01	10a;		2		2			1	375.00	375.00	2	
H5521	058	0	1	04	01	H5521_058_0	6	3	20% Coinsurance	01	12;		2		1	20	20	2			2	
H5521	058	0	1	04	01	H5521_058_0	6	4	$0	11	14d;	14c;16a;17b;	2		2			1	0.00	0.00	2	
H5521	058	0	1	04	01	H5521_058_0	6	5	14a: 0-50%	01	14a;		2		1	0	50	2			2	
H5521	058	0	1	04	01	H5521_058_0	6	6	11c 0-20%	01	11c;		2		1	0	20	2			2	
H5521	059	0	1	04	01	H5521_059_0	5	1	50 % Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	059	0	1	04	01	H5521_059_0	5	2	Ambulance $375	01	10a;		2		2			1	375.00	375.00	2	
H5521	059	0	1	04	01	H5521_059_0	5	3	20 % Tier	01	12;		2		1	20	20	2			2	
H5521	059	0	1	04	01	H5521_059_0	5	4	$0 Tier	11	14d;	14c;17b;	2		2			1	0.00	0.00	2	
H5521	059	0	1	04	01	H5521_059_0	5	5	0 - 50% Tier (14A)	01	14a;		2		1	0	50	2			2	
H5521	059	0	1	04	01	H5521_059_0	5	6	11c 0-20%	01	11c;		2		1	0	20	2			2	
H5521	060	0	1	04	01	H5521_060_0	5	1	50 % Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	060	0	1	04	01	H5521_060_0	5	2	Ambulance $375	01	10a;		2		2			1	375.00	375.00	2	
H5521	060	0	1	04	01	H5521_060_0	5	3	20 % Tier	01	12;		2		1	20	20	2			2	
H5521	060	0	1	04	01	H5521_060_0	5	4	$0 Tier	11	14d;	14c;17b;	2		2			1	0.00	0.00	2	
H5521	060	0	1	04	01	H5521_060_0	5	5	0 - 50% Tier (14A)	01	14a;		2		1	0	50	2			2	
H5521	060	0	1	04	01	H5521_060_0	5	6	11c 0-20%	01	11c;		2		1	0	20	2			2	
H5521	076	0	1	04	01	H5521_076_0	4	1	20% OON Tier	11	3-1;3-2;3-3;5;6;7b;7c;7e;7h;7i;8a1;8b1;8b2;8b3;9c;11b;14e;15;17b;	14b;17a;	2		1	20	20	2			2	
H5521	076	0	1	04	01	H5521_076_0	4	2	$300 OON	01	9a;9b;10a;		2		2			1	300.00	300.00	2	
H5521	076	0	1	04	01	H5521_076_0	4	3	20% OON	01	11a;12;		2		1	20	20	2			2	
H5521	076	0	1	04	01	H5521_076_0	4	4	$0 OON	10		14c;16a;17b;	2		2			1	0.00	0.00	2	
H5521	076	0	1	04	01	H5521_076_0	4	5	0-20% OON	01	11c;14a;		2		1	0	20	2			2	
H5521	076	0	1	04	01	H5521_076_0	4	6	$40 Copayment OON	11	7a;7d;7f;7g;9d;16b;17a;18a;	9d;18a;	2		2			1	40.00	40.00	2	
H5521	076	0	1	04	01	H5521_076_0	4	7	$20 Copayment OON	01	8a2;		2		2			1	20.00	20.00	2	
H5521	076	0	1	04	01	H5521_076_0	4	8	0% OON	01	14d;		2		1	0	0	2			2	
H5521	077	0	1	04	01	H5521_077_0	4	1	30% OON Tier	11	3-1;3-2;3-3;5;6;7b;7c;7e;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14e;15;17b;	14b;17a;	2		1	30	30	2			2	
H5521	077	0	1	04	01	H5521_077_0	4	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	077	0	1	04	01	H5521_077_0	4	3	20% OON	01	12;		2		1	20	20	2			2	
H5521	077	0	1	04	01	H5521_077_0	4	4	$0 Copayment OON	10		14c;16a;17b;18b;	2		2			1	0.00	0.00	2	
H5521	077	0	1	04	01	H5521_077_0	4	5	0-30%	01	14a;		2		1	0	30	2			2	
H5521	077	0	1	04	01	H5521_077_0	4	6	$45 Copayment OON	11	7a;7d;7f;7g;9d;16b;17a;18a;	9d;18a;	2		2			1	45.00	45.00	2	
H5521	077	0	1	04	01	H5521_077_0	4	7	0% OON	01	14d;		2		1	0	0	2			2	
H5521	077	0	1	04	01	H5521_077_0	4	8	0-20%	01	11c;		2		1	0	20	2			2	
H5521	081	0	1	04	01	H5521_081_0	5	1	40%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	9d;17a;18a;	2		1	40	40	2			2	
H5521	081	0	1	04	01	H5521_081_0	5	2	$0	11	14a;14d;	14b;14c;16a;17b;	2		2			1	0.00	0.00	2	
H5521	081	0	1	04	01	H5521_081_0	5	3	$300 Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	081	0	1	04	01	H5521_081_0	5	4	0%-20% Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H5521	082	0	1	04	01	H5521_082_0	3	1	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	082	0	1	04	01	H5521_082_0	3	2	$400	01	10a;		2		2			1	400.00	400.00	2	
H5521	082	0	1	04	01	H5521_082_0	3	3	20%	01	12;		2		1	20	20	2			2	
H5521	082	0	1	04	01	H5521_082_0	3	4	$0	11	14d;	14c;	2		2			1	0.00	0.00	2	
H5521	082	0	1	04	01	H5521_082_0	3	5	0%-50%	01	14a;		2		1	0	50	2			2	
H5521	082	0	1	04	01	H5521_082_0	3	6	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	083	0	1	04	01	H5521_083_0	3	1	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	083	0	1	04	01	H5521_083_0	3	2	$350	01	10a;		2		2			1	350.00	350.00	2	
H5521	083	0	1	04	01	H5521_083_0	3	3	20%	01	12;		2		1	20	20	2			2	
H5521	083	0	1	04	01	H5521_083_0	3	4	$0	11	14d;	14c;	2		2			1	0.00	0.00	2	
H5521	083	0	1	04	01	H5521_083_0	3	5	0%-50%	01	14a;		2		1	0	50	2			2	
H5521	083	0	1	04	01	H5521_083_0	3	6	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	084	0	1	04	01	H5521_084_0	3	1	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	084	0	1	04	01	H5521_084_0	3	2	$350	01	10a;		2		2			1	350.00	350.00	2	
H5521	084	0	1	04	01	H5521_084_0	3	3	20%	01	12;		2		1	20	20	2			2	
H5521	084	0	1	04	01	H5521_084_0	3	4	$0	11	14d;	14c;	2		2			1	0.00	0.00	2	
H5521	084	0	1	04	01	H5521_084_0	3	5	0%-50%	01	14a;		2		1	0	50	2			2	
H5521	084	0	1	04	01	H5521_084_0	3	6	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	085	0	1	04	01	H5521_085_0	6	1	50% Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	085	0	1	04	01	H5521_085_0	6	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	085	0	1	04	01	H5521_085_0	6	3	ESRD	01	12;		2		1	20	20	2			2	
H5521	085	0	1	04	01	H5521_085_0	6	4	$0 copay	11	14d;	14c;	2		2			1	0.00	0.00	2	
H5521	085	0	1	04	01	H5521_085_0	6	5	Medicare-covered Preventive Services	01	14a;		2		1	0	50	2			2	
H5521	085	0	1	04	01	H5521_085_0	6	6	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	086	0	1	04	01	H5521_086_0	4	1	35%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	35	35	2			2	
H5521	086	0	1	04	01	H5521_086_0	4	2	Ambulance	01	10a;		2		2			1	325.00	325.00	2	
H5521	086	0	1	04	01	H5521_086_0	4	3	20% Tier	01	12;		2		1	20	20	2			2	
H5521	086	0	1	04	01	H5521_086_0	4	4	0%-35% Tier	01	14a;		2		1	0	35	2			2	
H5521	086	0	1	04	01	H5521_086_0	4	5	0% Tier	11	14d;	14c;16a;	2		1	0	0	2			2	
H5521	086	0	1	04	01	H5521_086_0	4	6	OTC $25 monthly	10		13b;	1	25.00	2			1	0.00	0.00	2	
H5521	086	0	1	04	01	H5521_086_0	4	7	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	087	0	1	04	01	H5521_087_0	4	1	50% Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	087	0	1	04	01	H5521_087_0	4	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	087	0	1	04	01	H5521_087_0	4	3	ESRD and Kidney Disease Ed	01	12;		2		1	20	20	2			2	
H5521	087	0	1	04	01	H5521_087_0	4	4	$0 copay	11	14d;	14c;	2		2			1	0.00	0.00	2	
H5521	087	0	1	04	01	H5521_087_0	4	5	Medicare-covered Preventive Services	01	14a;		2		1	0	50	2			2	
H5521	087	0	1	04	01	H5521_087_0	4	6	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	088	0	1	04	01	H5521_088_0	4	1	50% Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	088	0	1	04	01	H5521_088_0	4	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	088	0	1	04	01	H5521_088_0	4	3	ESRD	01	12;		2		1	20	20	2			2	
H5521	088	0	1	04	01	H5521_088_0	4	4	$0 copay	11	14d;	14c;	2		2			1	0.00	0.00	2	
H5521	088	0	1	04	01	H5521_088_0	4	5	Medicare-covered Preventive Services	01	14a;		2		1	0	50	2			2	
H5521	088	0	1	04	01	H5521_088_0	4	6	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	089	0	1	04	01	H5521_089_0	4	1	50% Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	089	0	1	04	01	H5521_089_0	4	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	089	0	1	04	01	H5521_089_0	4	3	ESRD	01	12;		2		1	20	20	2			2	
H5521	089	0	1	04	01	H5521_089_0	4	4	$0 copay	11	14d;	14c;	2		2			1	0.00	0.00	2	
H5521	089	0	1	04	01	H5521_089_0	4	5	Medicare-covered Preventive Services	01	14a;		2		1	0	50	2			2	
H5521	089	0	1	04	01	H5521_089_0	4	6	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	090	0	1	04	01	H5521_090_0	4	1	50% Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	090	0	1	04	01	H5521_090_0	4	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	090	0	1	04	01	H5521_090_0	4	3	ESRD	01	12;		2		1	20	20	2			2	
H5521	090	0	1	04	01	H5521_090_0	4	4	$0 copay	11	14d;	14c;	2		2			1	0.00	0.00	2	
H5521	090	0	1	04	01	H5521_090_0	4	5	Medicare-covered Preventive Services	01	14a;		2		1	0	50	2			2	
H5521	090	0	1	04	01	H5521_090_0	4	6	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	091	0	1	04	01	H5521_091_0	5	1	40%	01	5;6;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;12;15;17b;		2		1	40	40	2			2	
H5521	091	0	1	04	01	H5521_091_0	5	2	$0	11	14d;14e;	14b;14c;17a;	2		2			1	0.00	0.00	2	
H5521	091	0	1	04	01	H5521_091_0	5	3	$300-Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	091	0	1	04	01	H5521_091_0	5	4	$50	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;9d;16b;17a;18a;	9d;18a;	2		2			1	50.00	50.00	2	
H5521	091	0	1	04	01	H5521_091_0	5	5	$150 Allowance	10		16a;	2		2			1	0.00	0.00	2	
H5521	091	0	1	04	01	H5521_091_0	5	6	$100 Allowance	10		17b;	2		2			1	0.00	0.00	2	
H5521	091	0	1	04	01	H5521_091_0	5	7	0-40%	01	14a;		2		1	0	40	2			2	
H5521	091	0	1	04	01	H5521_091_0	5	8	0%-20% Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H5521	091	0	1	04	01	H5521_091_0	5	9	$50/40%-Prosthetics/Medical Supplies	01	11b;		2		1	40	40	1	50.00	50.00	2	
H5521	092	0	1	04	01	H5521_092_0	4	1	50 % Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	092	0	1	04	01	H5521_092_0	4	2	Ambulance $375	01	10a;		2		2			1	375.00	375.00	2	
H5521	092	0	1	04	01	H5521_092_0	4	3	20 % Tier	01	12;		2		1	20	20	2			2	
H5521	092	0	1	04	01	H5521_092_0	4	4	$0 Tier	11	14d;	14c;16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H5521	092	0	1	04	01	H5521_092_0	4	5	0 - 50% Tier (14A)	01	14a;		2		1	0	50	2			2	
H5521	092	0	1	04	01	H5521_092_0	4	6	$25 OTC	10		13b;	1	25.00	2			1	0.00	0.00	2	
H5521	092	0	1	04	01	H5521_092_0	4	7	11c 0-20%	01	11c;		2		1	0	20	2			2	
H5521	094	0	1	04	01	H5521_094_0	4	1	50 % Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	094	0	1	04	01	H5521_094_0	4	2	Ambulance $375	01	10a;		2		2			1	375.00	375.00	2	
H5521	094	0	1	04	01	H5521_094_0	4	3	20 % Tier	01	12;		2		1	20	20	2			2	
H5521	094	0	1	04	01	H5521_094_0	4	4	$0 Tier	11	14d;	14c;16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H5521	094	0	1	04	01	H5521_094_0	4	5	0 - 50% Tier (14A)	01	14a;		2		1	0	50	2			2	
H5521	094	0	1	04	01	H5521_094_0	4	6	$25 OTC	10		13b;	1	25.00	2			1	0.00	0.00	2	
H5521	094	0	1	04	01	H5521_094_0	4	7	11c 0-20%	01	11c;		2		1	0	20	2			2	
H5521	094	0	1	04	01	H5521_094_0	4	8	dme	01	11a;		2		1	40	40	2			2	
H5521	095	0	1	04	01	H5521_095_0	4	1	20%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	20	20	2			2	
H5521	095	0	1	04	01	H5521_095_0	4	2	$315 Ambulance	01	10a;		2		2			1	315.00	315.00	2	
H5521	095	0	1	04	01	H5521_095_0	4	3	$0	11	14d;	14c;17b;18b;	2		2			1	0.00	0.00	2	
H5521	095	0	1	04	01	H5521_095_0	4	4	Preventive Dental	10		16a;	2		1	30	30	2			1	75.00
H5521	095	0	1	04	01	H5521_095_0	4	5	0%-20%	01	14a;		2		1	0	20	2			2	
H5521	095	0	1	04	01	H5521_095_0	4	6	0-20% Lifescan preferred vendor	01	11c;		2		1	0	20	2			2	
H5521	099	0	1	04	01	H5521_099_0	3	1	50% Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	099	0	1	04	01	H5521_099_0	3	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	099	0	1	04	01	H5521_099_0	3	3	20% Tier	01	12;		2		1	20	20	2			2	
H5521	099	0	1	04	01	H5521_099_0	3	4	0%-50% Tier	01	14a;		2		1	0	50	2			2	
H5521	099	0	1	04	01	H5521_099_0	3	5	0% Tier	11	14d;	14c;16a;17b;	2		1	0	0	2			2	
H5521	099	0	1	04	01	H5521_099_0	3	6	OTC $25 Monthly	10		13b;	1	25.00	2			1	0.00	0.00	2	
H5521	099	0	1	04	01	H5521_099_0	3	7	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	100	0	1	04	01	H5521_100_0	4	1	40% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	40	40	2			2	
H5521	100	0	1	04	01	H5521_100_0	4	2	$325 copay	01	10a;		2		2			1	325.00	325.00	2	
H5521	100	0	1	04	01	H5521_100_0	4	3	$0	11	14d;	14c;16a;17b;18b;	2		2			1	0.00	0.00	2	
H5521	100	0	1	04	01	H5521_100_0	4	4	0%-40%	01	14a;		2		1	0	40	2			2	
H5521	100	0	1	04	01	H5521_100_0	4	5	0%-20% Range	01	11c;		2		1	0	20	2			2	
H5521	101	0	1	04	01	H5521_101_0	3	1	45% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	45	45	2			2	
H5521	101	0	1	04	01	H5521_101_0	3	2	$350 copay	01	10a;		2		2			1	350.00	350.00	2	
H5521	101	0	1	04	01	H5521_101_0	3	3	Supplemental Benefits	11	14d;	14c;16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H5521	101	0	1	04	01	H5521_101_0	3	4	OON Range preventive	01	14a;		2		1	0	45	2			2	
H5521	101	0	1	04	01	H5521_101_0	3	5	Diabetic Services	01	11c;		2		1	0	20	2			2	
H5521	102	0	1	04	01	H5521_102_0	3	1	40%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	40	40	2			2	
H5521	102	0	1	04	01	H5521_102_0	3	2	$350	01	10a;		2		2			1	350.00	350.00	2	
H5521	102	0	1	04	01	H5521_102_0	3	3	20%	01	12;		2		1	20	20	2			2	
H5521	102	0	1	04	01	H5521_102_0	3	4	$0	11	14d;	14c;	2		2			1	0.00	0.00	2	
H5521	102	0	1	04	01	H5521_102_0	3	5	0%-40%	01	14a;		2		1	0	40	2			2	
H5521	102	0	1	04	01	H5521_102_0	3	6	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	103	0	1	04	01	H5521_103_0	4	1	50 % Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	103	0	1	04	01	H5521_103_0	4	2	Ambulance $375	01	10a;		2		2			1	375.00	375.00	2	
H5521	103	0	1	04	01	H5521_103_0	4	3	20 % Tier	01	12;		2		1	20	20	2			2	
H5521	103	0	1	04	01	H5521_103_0	4	4	$0 Tier	11	14d;	14c;16a;17b;	2		2			1	0.00	0.00	2	
H5521	103	0	1	04	01	H5521_103_0	4	5	0 - 50% Tier (14A)	01	14a;		2		1	0	50	2			2	
H5521	103	0	1	04	01	H5521_103_0	4	6	11c 0-20%	01	11c;		2		1	0	20	2			2	
H5521	104	0	1	04	01	H5521_104_0	4	1	50 % Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	104	0	1	04	01	H5521_104_0	4	2	Ambulance $375	01	10a;		2		2			1	375.00	375.00	2	
H5521	104	0	1	04	01	H5521_104_0	4	3	20 % Tier	01	12;		2		1	20	20	2			2	
H5521	104	0	1	04	01	H5521_104_0	4	4	$0 Tier	11	14d;	14c;16a;17b;	2		2			1	0.00	0.00	2	
H5521	104	0	1	04	01	H5521_104_0	4	5	0 - 50% Tier (14A)	01	14a;		2		1	0	50	2			2	
H5521	104	0	1	04	01	H5521_104_0	4	6	11c 0-20%	01	11c;		2		1	0	20	2			2	
H5521	105	0	1	04	01	H5521_105_0	4	1	50% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	105	0	1	04	01	H5521_105_0	4	2	Ambulance - $375	01	10a;		2		2			1	375.00	375.00	2	
H5521	105	0	1	04	01	H5521_105_0	4	3	20% Coinsurance	01	12;		2		1	20	20	2			2	
H5521	105	0	1	04	01	H5521_105_0	4	4	$0	11	14d;	14c;16a;17b;	2		2			1	0.00	0.00	2	
H5521	105	0	1	04	01	H5521_105_0	4	5	14a: 0-50%	01	14a;		2		1	0	50	2			2	
H5521	105	0	1	04	01	H5521_105_0	4	6	11c 0-20%	01	11c;		2		1	0	20	2			2	
H5521	107	0	1	04	01	H5521_107_0	4	1	50 % Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	107	0	1	04	01	H5521_107_0	4	2	Ambulance $375	01	10a;		2		2			1	375.00	375.00	2	
H5521	107	0	1	04	01	H5521_107_0	4	3	20 % Tier	01	12;		2		1	20	20	2			2	
H5521	107	0	1	04	01	H5521_107_0	4	4	$0 Tier	11	14d;	14c;16a;17b;	2		2			1	0.00	0.00	2	
H5521	107	0	1	04	01	H5521_107_0	4	5	0 - 50% Tier (14A)	01	14a;		2		1	0	50	2			2	
H5521	107	0	1	04	01	H5521_107_0	4	6	11c 0-20%	01	11c;		2		1	0	20	2			2	
H5521	108	0	1	04	01	H5521_108_0	4	1	50 % Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	108	0	1	04	01	H5521_108_0	4	2	Ambulance $375	01	10a;		2		2			1	375.00	375.00	2	
H5521	108	0	1	04	01	H5521_108_0	4	3	20 % Tier	01	12;		2		1	20	20	2			2	
H5521	108	0	1	04	01	H5521_108_0	4	4	$0 Tier	11	14d;	14c;16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H5521	108	0	1	04	01	H5521_108_0	4	5	0 - 50% Tier (14A)	01	14a;		2		1	0	50	2			2	
H5521	108	0	1	04	01	H5521_108_0	4	6	$25 OTC	10		13b;	1	25.00	2			1	0.00	0.00	2	
H5521	108	0	1	04	01	H5521_108_0	4	7	11c 0-20%	01	11c;		2		1	0	20	2			2	
H5521	109	0	1	04	01	H5521_109_0	4	1	50 % Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	109	0	1	04	01	H5521_109_0	4	2	Ambulance $375	01	10a;		2		2			1	375.00	375.00	2	
H5521	109	0	1	04	01	H5521_109_0	4	3	20 % Tier	01	12;		2		1	20	20	2			2	
H5521	109	0	1	04	01	H5521_109_0	4	4	$0 Tier	11	14d;	14c;16a;17b;	2		2			1	0.00	0.00	2	
H5521	109	0	1	04	01	H5521_109_0	4	5	0 - 50% Tier (14A)	01	14a;		2		1	0	50	2			2	
H5521	109	0	1	04	01	H5521_109_0	4	6	11c 0-20	01	11c;		2		1	0	20	2			2	
H5521	110	0	1	04	01	H5521_110_0	3	1	30% OON Tier	11	3-1;3-2;3-3;5;6;7b;7c;7e;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14e;15;17b;	14b;17a;	2		1	30	30	2			2	
H5521	110	0	1	04	01	H5521_110_0	3	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	110	0	1	04	01	H5521_110_0	3	3	20% OON	01	12;		2		1	20	20	2			2	
H5521	110	0	1	04	01	H5521_110_0	3	4	$0 OON	10		14c;16a;	2		2			1	0.00	0.00	2	
H5521	110	0	1	04	01	H5521_110_0	3	5	0-30%	01	14a;		2		1	0	30	2			2	
H5521	110	0	1	04	01	H5521_110_0	3	6	$50 Copayment OON	11	7a;7d;7f;7g;9d;16b;17a;18a;	9d;18a;	2		2			1	50.00	50.00	2	
H5521	110	0	1	04	01	H5521_110_0	3	7	0% OON	01	14d;		2		1	0	0	2			2	
H5521	110	0	1	04	01	H5521_110_0	3	8	0-20%	01	11c;		2		1	0	20	2			2	
H5521	111	0	1	04	01	H5521_111_0	3	1	30% OON Tier	11	3-1;3-2;3-3;5;6;7b;7c;7e;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14e;15;17b;	14b;17a;	2		1	30	30	2			2	
H5521	111	0	1	04	01	H5521_111_0	3	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	111	0	1	04	01	H5521_111_0	3	3	20% OON	01	12;		2		1	20	20	2			2	
H5521	111	0	1	04	01	H5521_111_0	3	4	$0 Copayment OON	10		14c;16a;17b;	2		2			1	0.00	0.00	2	
H5521	111	0	1	04	01	H5521_111_0	3	5	0-30%	01	14a;		2		1	0	30	2			2	
H5521	111	0	1	04	01	H5521_111_0	3	6	$50 Copayment OON	11	7a;7d;7f;7g;9d;16b;17a;18a;	9d;18a;	2		2			1	50.00	50.00	2	
H5521	111	0	1	04	01	H5521_111_0	3	7	0% OON	01	14d;		2		1	0	0	2			2	
H5521	111	0	1	04	01	H5521_111_0	3	8	0-20% OON	01	11c;		2		1	0	20	2			2	
H5521	112	0	1	04	01	H5521_112_0	4	1	30% OON Tier	11	3-1;3-2;3-3;5;6;7b;7c;7e;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14e;15;17b;	14b;17a;	2		1	30	30	2			2	
H5521	112	0	1	04	01	H5521_112_0	4	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	112	0	1	04	01	H5521_112_0	4	3	20% OON	01	12;		2		1	20	20	2			2	
H5521	112	0	1	04	01	H5521_112_0	4	4	$0 Copayment OON	10		14c;17b;18b;	2		2			1	0.00	0.00	2	
H5521	112	0	1	04	01	H5521_112_0	4	5	0-30%	01	14a;		2		1	0	30	2			2	
H5521	112	0	1	04	01	H5521_112_0	4	6	$50 Copayment OON	11	7a;7d;7f;7g;9d;16b;17a;18a;	9d;18a;	2		2			1	50.00	50.00	2	
H5521	112	0	1	04	01	H5521_112_0	4	7	0% OON	01	14d;		2		1	0	0	2			2	
H5521	112	0	1	04	01	H5521_112_0	4	8	0-20%	01	11c;		2		1	0	20	2			2	
H5521	113	0	1	04	01	H5521_113_0	3	1	30% OON Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	30	30	2			2	
H5521	113	0	1	04	01	H5521_113_0	3	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	113	0	1	04	01	H5521_113_0	3	3	20% OON	01	12;		2		1	20	20	2			2	
H5521	113	0	1	04	01	H5521_113_0	3	4	$0 OON Tier	10		14c;16a;17b;18b;	2		2			1	0.00	0.00	2	
H5521	113	0	1	04	01	H5521_113_0	3	5	0-30%	01	14a;		2		1	0	30	2			2	
H5521	113	0	1	04	01	H5521_113_0	3	6	0% OON	01	14d;		2		1	0	0	2			2	
H5521	113	0	1	04	01	H5521_113_0	3	7	0-20%	01	11c;		2		1	0	20	2			2	
H5521	114	0	1	04	01	H5521_114_0	4	1	40%	01	5;6;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;12;15;17b;		2		1	40	40	2			2	
H5521	114	0	1	04	01	H5521_114_0	4	2	$0	11	14d;14e;	14b;14c;17a;18b;	2		2			1	0.00	0.00	2	
H5521	114	0	1	04	01	H5521_114_0	4	3	$300-Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	114	0	1	04	01	H5521_114_0	4	4	$50	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;9d;16b;17a;18a;	9d;18a;	2		2			1	50.00	50.00	2	
H5521	114	0	1	04	01	H5521_114_0	4	5	$150 Allowance	10		16a;	2		2			1	0.00	0.00	2	
H5521	114	0	1	04	01	H5521_114_0	4	6	$100 Allowance	10		17b;	2		2			1	0.00	0.00	2	
H5521	114	0	1	04	01	H5521_114_0	4	7	0-40%	01	14a;		2		1	0	40	2			2	
H5521	114	0	1	04	01	H5521_114_0	4	8	0%-20% Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H5521	114	0	1	04	01	H5521_114_0	4	9	$50/40%-Prosthetics/Medical Supplies	01	11b;		2		1	40	40	1	50.00	50.00	2	
H5521	115	0	1	04	01	H5521_115_0	4	1	35%	01	5;6;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;12;15;17b;		2		1	35	35	2			2	
H5521	115	0	1	04	01	H5521_115_0	4	2	$0	11	14d;14e;	14b;14c;17a;	2		2			1	0.00	0.00	2	
H5521	115	0	1	04	01	H5521_115_0	4	3	$300-Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	115	0	1	04	01	H5521_115_0	4	4	$45	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;9d;16b;17a;18a;	9d;18a;	2		2			1	45.00	45.00	2	
H5521	115	0	1	04	01	H5521_115_0	4	5	$250 Allowance	10		16a;	2		2			1	0.00	0.00	2	
H5521	115	0	1	04	01	H5521_115_0	4	6	$250 Allowance	10		17b;	2		2			1	0.00	0.00	2	
H5521	115	0	1	04	01	H5521_115_0	4	7	35%/$45-Prosthetics/Medical Supplies	01	11b;		2		1	35	35	1	45.00	45.00	2	
H5521	115	0	1	04	01	H5521_115_0	4	8	0%-20% Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H5521	115	0	1	04	01	H5521_115_0	4	9	0-35%	01	14a;		2		1	0	35	2			2	
H5521	116	0	1	04	01	H5521_116_0	4	1	35%	01	5;6;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;12;15;17b;		2		1	35	35	2			2	
H5521	116	0	1	04	01	H5521_116_0	4	10	$1000 Hearing Aids Allowance	10		18b;	2		2			1	0.00	0.00	2	
H5521	116	0	1	04	01	H5521_116_0	4	2	$0	11	14d;14e;	14b;14c;17a;	2		2			1	0.00	0.00	2	
H5521	116	0	1	04	01	H5521_116_0	4	3	$300-Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	116	0	1	04	01	H5521_116_0	4	4	$45	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;9d;16b;17a;18a;	9d;18a;	2		2			1	45.00	45.00	2	
H5521	116	0	1	04	01	H5521_116_0	4	5	$250 Dental Allowance	10		16a;	2		2			1	0.00	0.00	2	
H5521	116	0	1	04	01	H5521_116_0	4	6	$250 Allowance	10		17b;	2		2			1	0.00	0.00	2	
H5521	116	0	1	04	01	H5521_116_0	4	7	35%/$45	01	11b;		2		1	35	35	1	45.00	45.00	2	
H5521	116	0	1	04	01	H5521_116_0	4	8	0%-20% Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H5521	116	0	1	04	01	H5521_116_0	4	9	0%-35%	01	14a;		2		1	0	35	2			2	
H5521	117	0	1	04	01	H5521_117_0	3	1	30% OON Tier	11	3-1;3-2;3-3;5;6;7b;7c;7e;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14e;15;17b;	14b;17a;	2		1	30	30	2			2	
H5521	117	0	1	04	01	H5521_117_0	3	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	117	0	1	04	01	H5521_117_0	3	3	20% OON	01	12;		2		1	20	20	2			2	
H5521	117	0	1	04	01	H5521_117_0	3	4	14C 0	10		14c;16a;	2		2			1	0.00	0.00	2	
H5521	117	0	1	04	01	H5521_117_0	3	5	0-30% coinsurance	01	14a;		2		1	0	30	2			2	
H5521	117	0	1	04	01	H5521_117_0	3	6	$50 copayment	11	7a;7d;7f;7g;9d;16b;17a;18a;	9d;18a;	2		2			1	50.00	50.00	2	
H5521	117	0	1	04	01	H5521_117_0	3	7	0% OON	01	14d;		2		1	0	0	2			2	
H5521	117	0	1	04	01	H5521_117_0	3	8	0-20%	01	11c;		2		1	0	20	2			2	
H5521	118	0	1	04	01	H5521_118_0	4	1	20% OON Tier	11	3-1;3-2;3-3;5;6;7b;7c;7e;7h;7i;8a1;8b1;8b2;8b3;9c;11a;11b;14e;15;17b;	14b;17a;	2		1	20	20	2			2	
H5521	118	0	1	04	01	H5521_118_0	4	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	118	0	1	04	01	H5521_118_0	4	3	20% OON	01	12;		2		1	20	20	2			2	
H5521	118	0	1	04	01	H5521_118_0	4	4	$0 OON	10		14c;16a;17b;18b;	2		2			1	0.00	0.00	2	
H5521	118	0	1	04	01	H5521_118_0	4	5	0-20%	01	11c;14a;		2		1	0	20	2			2	
H5521	118	0	1	04	01	H5521_118_0	4	6	$45 Copayment OON	11	7a;7d;7f;7g;9d;16b;17a;18a;	9d;18a;	2		2			1	45.00	45.00	2	
H5521	118	0	1	04	01	H5521_118_0	4	7	$20 Copayment	01	8a2;		2		2			1	20.00	20.00	2	
H5521	118	0	1	04	01	H5521_118_0	4	8	0% OON	01	14d;		2		1	0	0	2			2	
H5521	118	0	1	04	01	H5521_118_0	4	9	$350 Copayment OON	01	9a;9b;		2		2			1	350.00	350.00	2	
H5521	119	0	1	04	01	H5521_119_0	3	1	30% OON Tier	11	3-1;3-2;3-3;5;6;7b;7c;7e;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14e;15;17b;	14b;17a;	2		1	30	30	2			2	
H5521	119	0	1	04	01	H5521_119_0	3	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	119	0	1	04	01	H5521_119_0	3	3	20% OON	01	12;		2		1	20	20	2			2	
H5521	119	0	1	04	01	H5521_119_0	3	4	$0 OON	10		14c;16a;17b;18b;	2		2			1	0.00	0.00	2	
H5521	119	0	1	04	01	H5521_119_0	3	5	0-30%	01	14a;		2		1	0	30	2			2	
H5521	119	0	1	04	01	H5521_119_0	3	6	$50 Copayment OON	11	7a;7d;7f;7g;9d;16b;17a;18a;	9d;18a;	2		2			1	50.00	50.00	2	
H5521	119	0	1	04	01	H5521_119_0	3	7	0% OON	01	14d;		2		1	0	0	2			2	
H5521	119	0	1	04	01	H5521_119_0	3	8	0-20%	01	11c;		2		1	0	20	2			2	
H5521	120	0	1	04	01	H5521_120_0	4	1	30% OON Tier	11	3-1;3-2;3-3;5;6;7b;7c;7e;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14e;15;17b;	14b;17a;	2		1	30	30	2			2	
H5521	120	0	1	04	01	H5521_120_0	4	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	120	0	1	04	01	H5521_120_0	4	3	20% OON	01	12;		2		1	20	20	2			2	
H5521	120	0	1	04	01	H5521_120_0	4	4	$0 OON	10		14c;17b;	2		2			1	0.00	0.00	2	
H5521	120	0	1	04	01	H5521_120_0	4	5	0-30% OON	01	14a;		2		1	0	30	2			2	
H5521	120	0	1	04	01	H5521_120_0	4	6	$50 Copayment OON	11	7a;7d;7f;7g;9d;16b;17a;18a;	9d;18a;	2		2			1	50.00	50.00	2	
H5521	120	0	1	04	01	H5521_120_0	4	7	0% OON	01	14d;		2		1	0	0	2			2	
H5521	120	0	1	04	01	H5521_120_0	4	8	0-20%	01	11c;		2		1	0	20	2			2	
H5521	121	0	1	04	01	H5521_121_0	3	1	30% OON Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	30	30	2			2	
H5521	121	0	1	04	01	H5521_121_0	3	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	121	0	1	04	01	H5521_121_0	3	3	20% OON	01	12;		2		1	20	20	2			2	
H5521	121	0	1	04	01	H5521_121_0	3	4	$0 OON	10		14c;16a;17b;	2		2			1	0.00	0.00	2	
H5521	121	0	1	04	01	H5521_121_0	3	5	0-30%	01	14a;		2		1	0	30	2			2	
H5521	121	0	1	04	01	H5521_121_0	3	6	0% OON	01	14d;		2		1	0	0	2			2	
H5521	121	0	1	04	01	H5521_121_0	3	7	0-20%	01	11c;		2		1	0	20	2			2	
H5521	122	0	1	04	01	H5521_122_0	4	1	20%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	20	20	2			2	
H5521	122	0	1	04	01	H5521_122_0	4	2	$195	01	10a;		2		2			1	195.00	195.00	2	
H5521	122	0	1	04	01	H5521_122_0	4	3	$0	11	14d;	14c;16a;17b;18b;	2		2			1	0.00	0.00	2	
H5521	122	0	1	04	01	H5521_122_0	4	4	0-20%	01	14a;		2		1	0	20	2			2	
H5521	122	0	1	04	01	H5521_122_0	4	5	0-20% Lifescan preferred vendor	01	11c;		2		1	0	20	2			2	
H5521	123	0	1	04	01	H5521_123_0	4	1	40% OON Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	40	40	2			2	
H5521	123	0	1	04	01	H5521_123_0	4	2	Ambulance	01	10a;		2		2			1	350.00	350.00	2	
H5521	123	0	1	04	01	H5521_123_0	4	3	20%	01	12;		2		1	20	20	2			2	
H5521	123	0	1	04	01	H5521_123_0	4	4	$0 OON Tier	10		14c;16a;17b;18b;	2		2			1	0.00	0.00	2	
H5521	123	0	1	04	01	H5521_123_0	4	5	0-40%	01	14a;		2		1	0	40	2			2	
H5521	123	0	1	04	01	H5521_123_0	4	6	0% OON	01	14d;		2		1	0	0	2			2	
H5521	123	0	1	04	01	H5521_123_0	4	7	0-20% OON	01	11c;		2		1	0	20	2			2	
H5521	124	0	1	04	01	H5521_124_0	3	1	40% OON Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	40	40	2			2	
H5521	124	0	1	04	01	H5521_124_0	3	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	124	0	1	04	01	H5521_124_0	3	3	20%	01	12;		2		1	20	20	2			2	
H5521	124	0	1	04	01	H5521_124_0	3	4	$0 Copayment OON	10		14c;16a;	2		2			1	0.00	0.00	2	
H5521	124	0	1	04	01	H5521_124_0	3	5	0-40	01	14a;		2		1	0	40	2			2	
H5521	124	0	1	04	01	H5521_124_0	3	6	0% OON	01	14d;		2		1	0	0	2			2	
H5521	124	0	1	04	01	H5521_124_0	3	7	0-20% OON	01	11c;		2		1	0	20	2			2	
H5521	125	0	1	04	01	H5521_125_0	5	1	40% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	40	40	2			2	
H5521	125	0	1	04	01	H5521_125_0	5	2	$300 copay	01	10a;		2		2			1	300.00	300.00	2	
H5521	125	0	1	04	01	H5521_125_0	5	3	20% coinsurance	01	12;		2		1	20	20	2			2	
H5521	125	0	1	04	01	H5521_125_0	5	4	0% Coinsurance	11	14d;	14c;17b;	2		1	0	0	2			2	
H5521	125	0	1	04	01	H5521_125_0	5	5	0%-40% Coinsurance	01	14a;		2		1	0	40	2			2	
H5521	125	0	1	04	01	H5521_125_0	5	6	0%-20%	01	11c;		2		1	0	20	2			2	
H5521	126	0	1	04	01	H5521_126_0	5	1	40% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	40	40	2			2	
H5521	126	0	1	04	01	H5521_126_0	5	2	$300 copay	01	10a;		2		2			1	300.00	300.00	2	
H5521	126	0	1	04	01	H5521_126_0	5	3	20% coinsurance	01	12;		2		1	20	20	2			2	
H5521	126	0	1	04	01	H5521_126_0	5	4	Supplemental Benefits	11	14d;	14c;17b;	2		1	0	0	2			2	
H5521	126	0	1	04	01	H5521_126_0	5	5	0%-40%	01	14a;		2		1	0	40	2			2	
H5521	126	0	1	04	01	H5521_126_0	5	6	0%-20% Range	01	11c;		2		1	0	20	2			2	
H5521	127	0	1	04	01	H5521_127_0	6	1	45% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	45	45	2			2	
H5521	127	0	1	04	01	H5521_127_0	6	2	$300 copay	01	10a;		2		2			1	300.00	300.00	2	
H5521	127	0	1	04	01	H5521_127_0	6	3	20% coinsurance	01	12;		2		1	20	20	2			2	
H5521	127	0	1	04	01	H5521_127_0	6	4	Supplemental Benefits	11	14d;	14c;17b;	2		1	0	0	2			2	
H5521	127	0	1	04	01	H5521_127_0	6	5	OON Range	01	14a;		2		1	0	45	2			2	
H5521	127	0	1	04	01	H5521_127_0	6	6	0%-20% Range	01	11c;		2		1	0	20	2			2	
H5521	128	0	1	04	01	H5521_128_0	3	1	40% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	40	40	2			2	
H5521	128	0	1	04	01	H5521_128_0	3	2	$250 copay	01	10a;		2		2			1	250.00	250.00	2	
H5521	128	0	1	04	01	H5521_128_0	3	3	20% coinsurance	01	12;		2		1	20	20	2			2	
H5521	128	0	1	04	01	H5521_128_0	3	4	0%	11	14d;	14c;17b;18b;	2		1	0	0	2			2	
H5521	128	0	1	04	01	H5521_128_0	3	5	OON Range	01	14a;		2		1	0	40	2			2	
H5521	128	0	1	04	01	H5521_128_0	3	6	$0	10		16a;	2		2			1	0.00	0.00	2	
H5521	128	0	1	04	01	H5521_128_0	3	7	0%-20% Range	01	11c;		2		1	0	20	2			2	
H5521	130	0	1	04	01	H5521_130_0	3	1	40% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	40	40	2			2	
H5521	130	0	1	04	01	H5521_130_0	3	2	$275 copay	01	10a;		2		2			1	275.00	275.00	2	
H5521	130	0	1	04	01	H5521_130_0	3	3	Supplemental Benefits	11	14d;	14c;16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H5521	130	0	1	04	01	H5521_130_0	3	4	OON Range	01	14a;		2		1	0	40	2			2	
H5521	130	0	1	04	01	H5521_130_0	3	5	Diabetic Services	01	11c;		2		1	0	20	2			2	
H5521	131	0	1	04	01	H5521_131_0	3	1	45% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	45	45	2			2	
H5521	131	0	1	04	01	H5521_131_0	3	2	$300 copay	01	10a;		2		2			1	300.00	300.00	2	
H5521	131	0	1	04	01	H5521_131_0	3	3	Supplemental Benefits	11	14d;	14c;16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H5521	131	0	1	04	01	H5521_131_0	3	4	OON Range	01	14a;		2		1	0	45	2			2	
H5521	131	0	1	04	01	H5521_131_0	3	5	Diabetic Services	01	11c;		2		1	0	20	2			2	
H5521	134	0	1	04	01	H5521_134_0	4	1	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	134	0	1	04	01	H5521_134_0	4	2	$300	01	10a;		2		2			1	300.00	300.00	2	
H5521	134	0	1	04	01	H5521_134_0	4	3	20%	01	12;		2		1	20	20	2			2	
H5521	134	0	1	04	01	H5521_134_0	4	4	$0	11	14d;	14c;16a;18b;	2		2			1	0.00	0.00	2	
H5521	134	0	1	04	01	H5521_134_0	4	5	0%-50%	01	14a;		2		1	0	50	2			2	
H5521	134	0	1	04	01	H5521_134_0	4	6	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	134	0	1	04	01	H5521_134_0	4	7	0% coins nmc	10		17b;	2		1	0	0	2			2	
H5521	139	0	1	04	01	H5521_139_0	4	1	$65 COPAY	11	3-1;3-2;3-3;7a;7c;7d;7e;7f;7g;7h;7i;9d;14e;16b;17a;18a;	9d;17a;	2		2			1	65.00	65.00	2	
H5521	139	0	1	04	01	H5521_139_0	4	2	30% or $65	01	11b;		2		1	30	30	1	65.00	65.00	2	
H5521	139	0	1	04	01	H5521_139_0	4	3	$55.00 COPAY	10		18a;	2		2			1	55.00	55.00	2	
H5521	139	0	1	04	01	H5521_139_0	4	4	0%-20% Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H5521	139	0	1	04	01	H5521_139_0	4	5	30% COINSURANCE	01	8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;		2		1	30	30	2			2	
H5521	139	0	1	04	01	H5521_139_0	4	6	$300 COPAY (AMBULANCE)	01	10a;		2		2			1	300.00	300.00	2	
H5521	139	0	1	04	01	H5521_139_0	4	7	25% COINSURANCE	01	5;6;7b;12;15;17b;		2		1	25	25	2			2	
H5521	139	0	1	04	01	H5521_139_0	4	8	$0 COPAY	11	14a;14d;	14b;14c;16a;17b;	2		2			1	0.00	0.00	2	
H5521	140	0	1	04	01	H5521_140_0	4	1	$55 COPAY	11	3-1;3-2;3-3;7a;7c;7d;7e;7f;7g;7h;7i;9d;14e;16b;17a;18a;	9d;17a;18a;	2		2			1	55.00	55.00	2	
H5521	140	0	1	04	01	H5521_140_0	4	2	$0 COPAY	11	14a;14d;	14b;14c;16a;17b;	2		2			1	0.00	0.00	2	
H5521	140	0	1	04	01	H5521_140_0	4	3	20% COINSURANCE	01	5;6;7b;12;15;17b;		2		1	20	20	2			2	
H5521	140	0	1	04	01	H5521_140_0	4	4	30% or $55	01	11b;		2		1	30	30	1	55.00	55.00	2	
H5521	140	0	1	04	01	H5521_140_0	4	5	30% COINSURANCE	01	8b2;11a;		2		1	30	30	2			2	
H5521	140	0	1	04	01	H5521_140_0	4	6	$250 COPAY (AMBULANCE)	01	10a;		2		2			1	250.00	250.00	2	
H5521	140	0	1	04	01	H5521_140_0	4	7	25% COINSURANCE	01	8a1;8a2;8b1;8b3;9a;9b;9c;		2		1	25	25	2			2	
H5521	140	0	1	04	01	H5521_140_0	4	8	0%-20% Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H5521	141	0	1	04	01	H5521_141_0	4	1	20%	01	5;6;7b;12;15;17b;		2		1	20	20	2			2	
H5521	141	0	1	04	01	H5521_141_0	4	2	25%	01	8a1;8a2;8b1;8b3;9a;9b;9c;		2		1	25	25	2			2	
H5521	141	0	1	04	01	H5521_141_0	4	3	30%/$55	01	11b;		2		1	30	30	1	55.00	55.00	2	
H5521	141	0	1	04	01	H5521_141_0	4	4	$0	11	14a;14d;	14b;14c;16a;17b;	2		2			1	0.00	0.00	2	
H5521	141	0	1	04	01	H5521_141_0	4	5	$55	11	3-1;3-2;3-3;7a;7c;7d;7e;7f;7g;7h;7i;9d;14e;16b;17a;18a;	9d;17a;18a;	2		2			1	55.00	55.00	2	
H5521	141	0	1	04	01	H5521_141_0	4	6	$300 Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	141	0	1	04	01	H5521_141_0	4	7	30% Coinsurance	01	8b2;11a;		2		1	30	30	2			2	
H5521	141	0	1	04	01	H5521_141_0	4	8	0%-20% Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H5521	142	0	1	04	01	H5521_142_0	3	1	35% Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	35	35	2			2	
H5521	142	0	1	04	01	H5521_142_0	3	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	142	0	1	04	01	H5521_142_0	3	3	20% Tier	01	12;		2		1	20	20	2			2	
H5521	142	0	1	04	01	H5521_142_0	3	4	0%-35% Tier	01	14a;		2		1	0	35	2			2	
H5521	142	0	1	04	01	H5521_142_0	3	5	0% Tier	11	14d;	14c;	2		1	0	0	2			2	
H5521	142	0	1	04	01	H5521_142_0	3	6	$0	10		16a;17b;	2		2			1	0.00	0.00	2	
H5521	142	0	1	04	01	H5521_142_0	3	7	OTC	10		13b;	1	20.00	2			1	0.00	0.00	2	
H5521	142	0	1	04	01	H5521_142_0	3	8	11c Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H5521	143	0	1	04	01	H5521_143_0	4	1	35% Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	35	35	2			2	
H5521	143	0	1	04	01	H5521_143_0	4	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	143	0	1	04	01	H5521_143_0	4	3	20% Tier	01	12;		2		1	20	20	2			2	
H5521	143	0	1	04	01	H5521_143_0	4	4	0% Tier	11	14d;	14c;	2		1	0	0	2			2	
H5521	143	0	1	04	01	H5521_143_0	4	5	0-35% Tier	01	14a;		2		1	0	35	2			2	
H5521	143	0	1	04	01	H5521_143_0	4	6	$0	10		16a;17b;	2		2			1	0.00	0.00	2	
H5521	143	0	1	04	01	H5521_143_0	4	7	OTC	10		13b;	1	20.00	2			1	0.00	0.00	2	
H5521	143	0	1	04	01	H5521_143_0	4	8	11C Diabetic Suupplies	01	11c;		2		1	0	20	2			2	
H5521	144	0	1	04	01	H5521_144_0	3	1	35% Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	35	35	2			2	
H5521	144	0	1	04	01	H5521_144_0	3	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	144	0	1	04	01	H5521_144_0	3	3	20% Tier	01	12;		2		1	20	20	2			2	
H5521	144	0	1	04	01	H5521_144_0	3	4	0%-35% Tier	01	14a;		2		1	0	35	2			2	
H5521	144	0	1	04	01	H5521_144_0	3	5	0% Tier	11	14d;	14c;	2		1	0	0	2			2	
H5521	144	0	1	04	01	H5521_144_0	3	6	$0	10		16a;17b;	2		2			1	0.00	0.00	2	
H5521	144	0	1	04	01	H5521_144_0	3	7	OTC	10		13b;	1	20.00	2			1	0.00	0.00	2	
H5521	144	0	1	04	01	H5521_144_0	3	8	11C Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H5521	145	0	1	04	01	H5521_145_0	5	1	50% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	145	0	1	04	01	H5521_145_0	5	2	Ambulance - $375	01	10a;		2		2			1	375.00	375.00	2	
H5521	145	0	1	04	01	H5521_145_0	5	3	20% Coinsurance	01	12;		2		1	20	20	2			2	
H5521	145	0	1	04	01	H5521_145_0	5	4	$0	11	14d;	14c;16a;17b;	2		2			1	0.00	0.00	2	
H5521	145	0	1	04	01	H5521_145_0	5	5	14a: 0-50%	01	14a;		2		1	0	50	2			2	
H5521	145	0	1	04	01	H5521_145_0	5	6	11c 0-20%	01	11c;		2		1	0	20	2			2	
H5521	146	0	1	04	01	H5521_146_0	4	1	50 % Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	146	0	1	04	01	H5521_146_0	4	2	Ambulance $375	01	10a;		2		2			1	375.00	375.00	2	
H5521	146	0	1	04	01	H5521_146_0	4	3	20 % Tier	01	12;		2		1	20	20	2			2	
H5521	146	0	1	04	01	H5521_146_0	4	4	$0 Tier	11	14d;	14c;16a;	2		2			1	0.00	0.00	2	
H5521	146	0	1	04	01	H5521_146_0	4	5	0 - 50% Tier (14A)	01	14a;		2		1	0	50	2			2	
H5521	146	0	1	04	01	H5521_146_0	4	6	11c 0-20	01	11c;		2		1	0	20	2			2	
H5521	147	0	1	04	01	H5521_147_0	5	1	50 % Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	147	0	1	04	01	H5521_147_0	5	2	Ambulance $375	01	10a;		2		2			1	375.00	375.00	2	
H5521	147	0	1	04	01	H5521_147_0	5	3	20 % Tier	01	12;		2		1	20	20	2			2	
H5521	147	0	1	04	01	H5521_147_0	5	4	$0 Tier	11	14d;	14c;16a;17b;	2		2			1	0.00	0.00	2	
H5521	147	0	1	04	01	H5521_147_0	5	5	0 - 50% Tier (14A)	01	14a;		2		1	0	50	2			2	
H5521	147	0	1	04	01	H5521_147_0	5	6	11c 0-20%	01	11c;		2		1	0	20	2			2	
H5521	148	0	1	04	01	H5521_148_0	3	1	50% Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	148	0	1	04	01	H5521_148_0	3	2	Ambulance	01	10a;		2		2			1	200.00	200.00	2	
H5521	148	0	1	04	01	H5521_148_0	3	3	20% Tier	01	12;		2		1	20	20	2			2	
H5521	148	0	1	04	01	H5521_148_0	3	4	0% Tier	11	14d;	14c;16a;17b;	2		1	0	0	2			2	
H5521	148	0	1	04	01	H5521_148_0	3	5	0%-50% Tier	01	14a;		2		1	0	50	2			2	
H5521	148	0	1	04	01	H5521_148_0	3	6	OTC $25 monthly	10		13b;	1	25.00	2			1	0.00	0.00	2	
H5521	148	0	1	04	01	H5521_148_0	3	7	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	149	0	1	04	01	H5521_149_0	3	1	50% Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	149	0	1	04	01	H5521_149_0	3	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	149	0	1	04	01	H5521_149_0	3	3	20% Tier	01	12;		2		1	20	20	2			2	
H5521	149	0	1	04	01	H5521_149_0	3	4	0% Tier	11	14d;	14c;16a;17b;	2		1	0	0	2			2	
H5521	149	0	1	04	01	H5521_149_0	3	5	0%-50% Tier	01	14a;		2		1	0	50	2			2	
H5521	149	0	1	04	01	H5521_149_0	3	6	OTC $25 monthly	10		13b;	1	25.00	2			1	0.00	0.00	2	
H5521	149	0	1	04	01	H5521_149_0	3	7	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	150	0	1	04	01	H5521_150_0	3	1	50% Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;18a;	2		1	50	50	2			2	
H5521	150	0	1	04	01	H5521_150_0	3	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	150	0	1	04	01	H5521_150_0	3	3	20% TIer	01	12;		2		1	20	20	2			2	
H5521	150	0	1	04	01	H5521_150_0	3	4	%0 Tier	11	14d;	14c;16a;17a;17b;	2		1	0	0	2			2	
H5521	150	0	1	04	01	H5521_150_0	3	5	0%-50% Tier	01	14a;		2		1	0	50	2			2	
H5521	150	0	1	04	01	H5521_150_0	3	6	OTC $25 Monthly	10		13b;	1	25.00	2			1	0.00	0.00	2	
H5521	150	0	1	04	01	H5521_150_0	3	7	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	151	0	1	04	01	H5521_151_0	3	1	50% Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;	2		1	50	50	2			2	
H5521	151	0	1	04	01	H5521_151_0	3	2	Ambulance	01	10a;		2		2			1	350.00	350.00	2	
H5521	151	0	1	04	01	H5521_151_0	3	3	20% Tier	01	12;		2		1	20	20	2			2	
H5521	151	0	1	04	01	H5521_151_0	3	4	0%-50% Tier	01	14a;		2		1	0	50	2			2	
H5521	151	0	1	04	01	H5521_151_0	3	5	0% Tier	11	14d;	14c;16a;17a;17b;18a;	2		1	0	0	2			2	
H5521	151	0	1	04	01	H5521_151_0	3	6	OTC $25 Monthly	10		13b;	1	25.00	2			1	0.00	0.00	2	
H5521	151	0	1	04	01	H5521_151_0	3	7	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	152	0	1	04	01	H5521_152_0	3	1	50% Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;	2		1	50	50	2			2	
H5521	152	0	1	04	01	H5521_152_0	3	2	Ambulance	01	10a;		2		2			1	350.00	350.00	2	
H5521	152	0	1	04	01	H5521_152_0	3	3	20% Tier	01	12;		2		1	20	20	2			2	
H5521	152	0	1	04	01	H5521_152_0	3	4	0% Tier	11	14d;	14c;16a;17a;17b;18a;	2		1	0	0	2			2	
H5521	152	0	1	04	01	H5521_152_0	3	5	0%-50% Tier	01	14a;		2		1	0	50	2			2	
H5521	152	0	1	04	01	H5521_152_0	3	6	OTC $25 Monthly	10		13b;	1	25.00	2			1	0.00	0.00	2	
H5521	152	0	1	04	01	H5521_152_0	3	7	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	153	0	1	04	01	H5521_153_0	3	1	50% Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;	2		1	50	50	2			2	
H5521	153	0	1	04	01	H5521_153_0	3	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	153	0	1	04	01	H5521_153_0	3	3	20% Tier	01	12;		2		1	20	20	2			2	
H5521	153	0	1	04	01	H5521_153_0	3	4	0% Tier	11	14d;	14c;16a;17a;17b;18a;	2		1	0	0	2			2	
H5521	153	0	1	04	01	H5521_153_0	3	5	0%-50% Tier	01	14a;		2		1	0	50	2			2	
H5521	153	0	1	04	01	H5521_153_0	3	6	OTC $25 Monthly	10		13b;	1	25.00	2			1	0.00	0.00	2	
H5521	153	0	1	04	01	H5521_153_0	3	7	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	154	0	1	04	01	H5521_154_0	4	1	20%	01	5;6;7b;12;15;17b;		2		1	20	20	2			2	
H5521	154	0	1	04	01	H5521_154_0	4	2	25%	01	8a1;8a2;8b1;8b3;9a;9b;9c;		2		1	25	25	2			2	
H5521	154	0	1	04	01	H5521_154_0	4	3	30%/$55	01	11b;		2		1	30	30	1	55.00	55.00	2	
H5521	154	0	1	04	01	H5521_154_0	4	4	$0	11	14a;14d;	14b;14c;16a;17b;	2		2			1	0.00	0.00	2	
H5521	154	0	1	04	01	H5521_154_0	4	5	$55	11	3-1;3-2;3-3;7a;7c;7d;7e;7f;7g;7h;7i;9d;14e;16b;17a;18a;	9d;17a;18a;	2		2			1	55.00	55.00	2	
H5521	154	0	1	04	01	H5521_154_0	4	6	$300 Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	154	0	1	04	01	H5521_154_0	4	7	30%	01	8b2;11a;		2		1	30	30	2			2	
H5521	154	0	1	04	01	H5521_154_0	4	8	0%-20% Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H5521	156	0	1	04	01	H5521_156_0	4	1	50% Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	156	0	1	04	01	H5521_156_0	4	2	Ambulance	01	10a;		2		2			1	250.00	250.00	2	
H5521	156	0	1	04	01	H5521_156_0	4	3	ESRD	01	12;		2		1	20	20	2			2	
H5521	156	0	1	04	01	H5521_156_0	4	4	$0 copay	11	14d;	14c;	2		2			1	0.00	0.00	2	
H5521	156	0	1	04	01	H5521_156_0	4	5	Medicare-covered Preventive Services	01	14a;		2		1	0	50	2			2	
H5521	156	0	1	04	01	H5521_156_0	4	6	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	156	0	1	04	01	H5521_156_0	4	7	0% Coins NMC	10		16a;17b;	2		1	0	0	2			2	
H5521	157	0	1	04	01	H5521_157_0	3	1	30% OON Tier	11	3-1;3-2;3-3;5;6;7b;7c;7e;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14e;15;17b;	14b;17a;	2		1	30	30	2			2	
H5521	157	0	1	04	01	H5521_157_0	3	2	Ambulance	01	10a;		2		2			1	275.00	275.00	2	
H5521	157	0	1	04	01	H5521_157_0	3	3	20% for ESRD	01	12;		2		1	20	20	2			2	
H5521	157	0	1	04	01	H5521_157_0	3	4	$0	10		14c;16a;17b;18b;	2		2			1	0.00	0.00	2	
H5521	157	0	1	04	01	H5521_157_0	3	5	0-30%	01	14a;		2		1	0	30	2			2	
H5521	157	0	1	04	01	H5521_157_0	3	6	OTC	10		13b;	1	20.00	2			1	0.00	0.00	2	
H5521	157	0	1	04	01	H5521_157_0	3	7	14D Kidney Disease Education	01	14d;		2		1	0	0	2			2	
H5521	157	0	1	04	01	H5521_157_0	3	8	$50 Copayment OON	11	7a;7d;7f;7g;9d;16b;17a;18a;	9d;18a;	2		2			1	50.00	50.00	2	
H5521	157	0	1	04	01	H5521_157_0	3	9	11C	01	11c;		2		1	0	20	2			2	
H5521	158	0	1	04	01	H5521_158_0	3	1	45% Tier	11	3-1;3-2;3-3;5;6;7b;7c;7e;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14e;15;17b;	14b;17a;	2		1	45	45	2			2	
H5521	158	0	1	04	01	H5521_158_0	3	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	158	0	1	04	01	H5521_158_0	3	3	20% Tier	01	12;		2		1	20	20	2			2	
H5521	158	0	1	04	01	H5521_158_0	3	4	0%-45% Tier	01	14a;		2		1	0	45	2			2	
H5521	158	0	1	04	01	H5521_158_0	3	5	0% Tier	11	14d;	14c;	2		1	0	0	2			2	
H5521	158	0	1	04	01	H5521_158_0	3	6	$0	10		16a;17b;	2		2			1	0.00	0.00	2	
H5521	158	0	1	04	01	H5521_158_0	3	7	OTC	10		13b;	1	20.00	2			1	0.00	0.00	2	
H5521	158	0	1	04	01	H5521_158_0	3	8	$50 OON Copay-PCP/ Specialist items	11	7a;7d;7f;7g;9d;16b;17a;18a;	9d;18a;	2		2			1	50.00	50.00	2	
H5521	158	0	1	04	01	H5521_158_0	3	9	11C Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H5521	159	0	1	04	01	H5521_159_0	3	1	45% Tier	11	3-1;3-2;3-3;5;6;7b;7c;7e;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14e;15;17b;	14b;17a;	2		1	45	45	2			2	
H5521	159	0	1	04	01	H5521_159_0	3	2	Ambulance	01	10a;		2		2			1	250.00	250.00	2	
H5521	159	0	1	04	01	H5521_159_0	3	3	20% Tier	01	12;		2		1	20	20	2			2	
H5521	159	0	1	04	01	H5521_159_0	3	4	0%-45% Tier	01	14a;		2		1	0	45	2			2	
H5521	159	0	1	04	01	H5521_159_0	3	5	0% Tier	11	14d;	14c;	2		1	0	0	2			2	
H5521	159	0	1	04	01	H5521_159_0	3	6	$0	10		16a;17b;	2		2			1	0.00	0.00	2	
H5521	159	0	1	04	01	H5521_159_0	3	7	OTC	10		13b;	1	20.00	2			1	0.00	0.00	2	
H5521	159	0	1	04	01	H5521_159_0	3	8	$50 OON Copay	11	7a;7d;7f;7g;9d;16b;17a;18a;	9d;18a;	2		2			1	50.00	50.00	2	
H5521	159	0	1	04	01	H5521_159_0	3	9	11C Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H5521	160	0	1	04	01	H5521_160_0	3	1	45% OON Tier	11	3-1;3-2;3-3;5;6;7b;7c;7e;7h;7i;8a1;8a2;8b1;8b3;9a;9b;9c;11a;11b;14e;15;17b;	14b;17a;	2		1	45	45	2			2	
H5521	160	0	1	04	01	H5521_160_0	3	2	Ambulance	01	10a;		2		2			1	250.00	250.00	2	
H5521	160	0	1	04	01	H5521_160_0	3	3	20%	01	8b2;12;		2		1	20	20	2			2	
H5521	160	0	1	04	01	H5521_160_0	3	4	14C 0	10		14c;16a;17b;	2		2			1	0.00	0.00	2	
H5521	160	0	1	04	01	H5521_160_0	3	5	0-45	01	14a;		2		1	0	45	2			2	
H5521	160	0	1	04	01	H5521_160_0	3	6	OTC	10		13b;	1	20.00	2			1	0.00	0.00	2	
H5521	160	0	1	04	01	H5521_160_0	3	7	$50 OON Copay	11	7a;7d;7f;7g;9d;16b;17a;18a;	9d;18a;	2		2			1	50.00	50.00	2	
H5521	160	0	1	04	01	H5521_160_0	3	8	0%	01	14d;		2		1	0	0	2			2	
H5521	160	0	1	04	01	H5521_160_0	3	9	11C Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H5521	167	0	1	04	01	H5521_167_0	5	1	50 % Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	167	0	1	04	01	H5521_167_0	5	2	Ambulance $375	01	10a;		2		2			1	375.00	375.00	2	
H5521	167	0	1	04	01	H5521_167_0	5	3	20 % Tier	01	12;		2		1	20	20	2			2	
H5521	167	0	1	04	01	H5521_167_0	5	4	$0 Tier	11	14d;	14c;16a;	2		2			1	0.00	0.00	2	
H5521	167	0	1	04	01	H5521_167_0	5	5	0 - 50% Tier (14A)	01	14a;		2		1	0	50	2			2	
H5521	167	0	1	04	01	H5521_167_0	5	6	40% Part B RX	01	15;		2		1	40	40	2			2	
H5521	167	0	1	04	01	H5521_167_0	5	7	11c 0-20%	01	11c;		2		1	0	20	2			2	
H5521	168	0	1	04	01	H5521_168_0	5	1	40%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	9d;17a;18a;	2		1	40	40	2			2	
H5521	168	0	1	04	01	H5521_168_0	5	2	$0	11	14a;14d;	14b;14c;	2		2			1	0.00	0.00	2	
H5521	168	0	1	04	01	H5521_168_0	5	3	$300 Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	168	0	1	04	01	H5521_168_0	5	4	0%-20% Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H5521	169	0	1	04	01	H5521_169_0	4	1	40%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	9d;17a;18a;	2		1	40	40	2			2	
H5521	169	0	1	04	01	H5521_169_0	4	2	$0	11	14a;14d;	14b;14c;16a;17b;	2		2			1	0.00	0.00	2	
H5521	169	0	1	04	01	H5521_169_0	4	3	$300 Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	169	0	1	04	01	H5521_169_0	4	4	0%-20% Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H5521	170	0	1	04	01	H5521_170_0	4	1	40%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	9d;17a;18a;	2		1	40	40	2			2	
H5521	170	0	1	04	01	H5521_170_0	4	2	$0	11	14a;14d;	14b;14c;16a;17b;	2		2			1	0.00	0.00	2	
H5521	170	0	1	04	01	H5521_170_0	4	3	$300 Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	170	0	1	04	01	H5521_170_0	4	4	0%-20% Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H5521	171	0	1	04	01	H5521_171_0	4	1	40%	01	5;6;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;12;15;17b;		2		1	40	40	2			2	
H5521	171	0	1	04	01	H5521_171_0	4	2	$0	11	14d;14e;	14b;14c;17a;18b;	2		2			1	0.00	0.00	2	
H5521	171	0	1	04	01	H5521_171_0	4	3	$250 Ambulance	01	10a;		2		2			1	250.00	250.00	2	
H5521	171	0	1	04	01	H5521_171_0	4	4	$50	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;9d;16b;17a;18a;	9d;18a;	2		2			1	50.00	50.00	2	
H5521	171	0	1	04	01	H5521_171_0	4	5	$250 Preventive Dental Allowance	10		16a;	2		2			1	0.00	0.00	2	
H5521	171	0	1	04	01	H5521_171_0	4	6	$250 Eyewear Allowance	10		17b;	2		2			1	0.00	0.00	2	
H5521	171	0	1	04	01	H5521_171_0	4	7	0-40%	01	14a;		2		1	0	40	2			2	
H5521	171	0	1	04	01	H5521_171_0	4	8	0%-20% Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H5521	171	0	1	04	01	H5521_171_0	4	9	$50/40%	01	11b;		2		1	40	40	1	50.00	50.00	2	
H5521	177	0	1	04	01	H5521_177_0	4	1	40%	01	5;6;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;12;15;17b;		2		1	40	40	2			2	
H5521	177	0	1	04	01	H5521_177_0	4	2	$0	11	14d;14e;	14b;14c;17a;	2		2			1	0.00	0.00	2	
H5521	177	0	1	04	01	H5521_177_0	4	3	$300	01	10a;		2		2			1	300.00	300.00	2	
H5521	177	0	1	04	01	H5521_177_0	4	4	$50	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;9d;16b;17a;18a;	9d;18a;	2		2			1	50.00	50.00	2	
H5521	177	0	1	04	01	H5521_177_0	4	5	$250 Preventive Dental  Allowance	10		16a;	2		2			1	0.00	0.00	2	
H5521	177	0	1	04	01	H5521_177_0	4	6	$250 Eyewear Allowance	10		17b;	2		2			1	0.00	0.00	2	
H5521	177	0	1	04	01	H5521_177_0	4	7	0-40%	01	14a;		2		1	0	40	2			2	
H5521	177	0	1	04	01	H5521_177_0	4	8	0%-20% Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H5521	177	0	1	04	01	H5521_177_0	4	9	$50/40%	01	11b;		2		1	40	40	1	50.00	50.00	2	
H5521	178	0	1	04	01	H5521_178_0	4	1	40%	01	3-1;3-2;3-3;5;6;7b;7c;7e;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;12;15;17b;		2		1	40	40	2			2	
H5521	178	0	1	04	01	H5521_178_0	4	2	$0	11	14d;14e;	14b;14c;17a;	2		2			1	0.00	0.00	2	
H5521	178	0	1	04	01	H5521_178_0	4	3	$300 Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	178	0	1	04	01	H5521_178_0	4	4	$40	11	7a;7d;7f;7g;9d;16b;17a;18a;	9d;18a;	2		2			1	40.00	40.00	2	
H5521	178	0	1	04	01	H5521_178_0	4	5	$250 Dental Allowance	10		16a;	2		2			1	0.00	0.00	2	
H5521	178	0	1	04	01	H5521_178_0	4	6	$250 Eyewear Allowance	10		17b;	2		2			1	0.00	0.00	2	
H5521	178	0	1	04	01	H5521_178_0	4	7	0%-40%	01	14a;		2		1	0	40	2			2	
H5521	178	0	1	04	01	H5521_178_0	4	8	0%-20% Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H5521	178	0	1	04	01	H5521_178_0	4	9	$40/40%	01	11b;		2		1	40	40	1	40.00	40.00	2	
H5521	179	0	1	04	01	H5521_179_0	3	1	40%	01	5;6;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;12;15;17b;		2		1	40	40	2			2	
H5521	179	0	1	04	01	H5521_179_0	3	2	$0	11	14d;14e;	14b;14c;17a;	2		2			1	0.00	0.00	2	
H5521	179	0	1	04	01	H5521_179_0	3	3	$250 Ambulance	01	10a;		2		2			1	250.00	250.00	2	
H5521	179	0	1	04	01	H5521_179_0	3	4	$50	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;9d;16b;17a;18a;	9d;18a;	2		2			1	50.00	50.00	2	
H5521	179	0	1	04	01	H5521_179_0	3	5	$250 Preventive Dental Allowance	10		16a;	2		2			1	0.00	0.00	2	
H5521	179	0	1	04	01	H5521_179_0	3	6	$250 Eyewear Allowance	10		17b;	2		2			1	0.00	0.00	2	
H5521	179	0	1	04	01	H5521_179_0	3	7	0-40%	01	14a;		2		1	0	40	2			2	
H5521	179	0	1	04	01	H5521_179_0	3	8	0%-20% Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H5521	179	0	1	04	01	H5521_179_0	3	9	$50/40%	01	11b;		2		1	40	40	1	50.00	50.00	2	
H5521	183	0	1	04	01	H5521_183_0	4	1	40%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	9d;17a;18a;	2		1	40	40	2			2	
H5521	183	0	1	04	01	H5521_183_0	4	2	$0	11	14a;14d;	14b;14c;16a;17b;	2		2			1	0.00	0.00	2	
H5521	183	0	1	04	01	H5521_183_0	4	3	$300 Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	183	0	1	04	01	H5521_183_0	4	4	0%-20% Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H5521	184	0	1	04	01	H5521_184_0	3	1	40% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	40	40	2			2	
H5521	184	0	1	04	01	H5521_184_0	3	2	$275 copay	01	10a;		2		2			1	275.00	275.00	2	
H5521	184	0	1	04	01	H5521_184_0	3	3	Supplemental Benefits	11	14d;	14c;16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H5521	184	0	1	04	01	H5521_184_0	3	4	OON Range preventive	01	14a;		2		1	0	40	2			2	
H5521	184	0	1	04	01	H5521_184_0	3	5	Diabetic services	01	11c;		2		1	0	20	2			2	
H5521	185	0	1	04	01	H5521_185_0	3	1	40% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	40	40	2			2	
H5521	185	0	1	04	01	H5521_185_0	3	2	$275 copay	01	10a;		2		2			1	275.00	275.00	2	
H5521	185	0	1	04	01	H5521_185_0	3	3	$0	11	14d;	14c;16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H5521	185	0	1	04	01	H5521_185_0	3	4	0%-40%	01	14a;		2		1	0	40	2			2	
H5521	185	0	1	04	01	H5521_185_0	3	5	0%-20% Range	01	11c;		2		1	0	20	2			2	
H5521	186	0	1	04	01	H5521_186_0	3	1	40% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	40	40	2			2	
H5521	186	0	1	04	01	H5521_186_0	3	2	$275 copay	01	10a;		2		2			1	275.00	275.00	2	
H5521	186	0	1	04	01	H5521_186_0	3	3	$0	11	14d;	14c;16a;17b;18b;	2		2			1	0.00	0.00	2	
H5521	186	0	1	04	01	H5521_186_0	3	4	0%-40%	01	14a;		2		1	0	40	2			2	
H5521	186	0	1	04	01	H5521_186_0	3	5	0%-20% Range	01	11c;		2		1	0	20	2			2	
H5521	187	0	1	04	01	H5521_187_0	3	1	40% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	40	40	2			2	
H5521	187	0	1	04	01	H5521_187_0	3	2	$275 copay	01	10a;		2		2			1	275.00	275.00	2	
H5521	187	0	1	04	01	H5521_187_0	3	3	Supplemental Benefits	11	14d;	14c;16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H5521	187	0	1	04	01	H5521_187_0	3	4	OON Range preventive	01	14a;		2		1	0	40	2			2	
H5521	187	0	1	04	01	H5521_187_0	3	5	Diabetic services Range	01	11c;		2		1	0	20	2			2	
H5521	190	0	1	04	01	H5521_190_0	4	1	50% Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	190	0	1	04	01	H5521_190_0	4	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H5521	190	0	1	04	01	H5521_190_0	4	3	20% Tier	01	12;		2		1	20	20	2			2	
H5521	190	0	1	04	01	H5521_190_0	4	4	0%-50% Tier	01	14a;		2		1	0	50	2			2	
H5521	190	0	1	04	01	H5521_190_0	4	5	0% Tier	11	14d;	14c;16a;16b;17b;	2		1	0	0	2			2	
H5521	190	0	1	04	01	H5521_190_0	4	6	OTC $25 monthly	10		13b;	1	25.00	2			1	0.00	0.00	2	
H5521	190	0	1	04	01	H5521_190_0	4	7	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	194	0	1	04	01	H5521_194_0	3	1	50% Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	194	0	1	04	01	H5521_194_0	3	2	Ambulance	01	10a;		2		2			1	350.00	350.00	2	
H5521	194	0	1	04	01	H5521_194_0	3	3	20% Tier	01	12;		2		1	20	20	2			2	
H5521	194	0	1	04	01	H5521_194_0	3	4	0% Tier	11	14d;	14c;16a;	2		1	0	0	2			2	
H5521	194	0	1	04	01	H5521_194_0	3	5	0%-50% Tier	01	14a;		2		1	0	50	2			2	
H5521	194	0	1	04	01	H5521_194_0	3	6	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	195	0	1	04	01	H5521_195_0	4	1	50% Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;18a;	2		1	50	50	2			2	
H5521	195	0	1	04	01	H5521_195_0	4	2	Ambulance	01	10a;		2		2			1	350.00	350.00	2	
H5521	195	0	1	04	01	H5521_195_0	4	3	20% TIer	01	12;		2		1	20	20	2			2	
H5521	195	0	1	04	01	H5521_195_0	4	4	0% Tier	11	14d;	14c;17a;17b;	2		1	0	0	2			2	
H5521	195	0	1	04	01	H5521_195_0	4	5	0%-50% Tier	01	14a;		2		1	0	50	2			2	
H5521	195	0	1	04	01	H5521_195_0	4	6	OTC $20 Monthly	10		13b;	1	20.00	2			1	0.00	0.00	2	
H5521	195	0	1	04	01	H5521_195_0	4	7	0% - 20%	01	11c;		2		1	0	20	2			2	
H5521	196	0	1	04	01	H5521_196_0	3	1	45% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	45	45	2			2	
H5521	196	0	1	04	01	H5521_196_0	3	2	$350 copay	01	10a;		2		2			1	350.00	350.00	2	
H5521	196	0	1	04	01	H5521_196_0	3	3	Supplemental Benefits	11	14d;	14c;16a;17b;	2		2			1	0.00	0.00	2	
H5521	196	0	1	04	01	H5521_196_0	3	4	OON Range preventive	01	14a;		2		1	0	45	2			2	
H5521	196	0	1	04	01	H5521_196_0	3	5	Diabetic Services 0%-20% Range	01	11c;		2		1	0	20	2			2	
H5521	197	0	1	04	01	H5521_197_0	3	1	40% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	40	40	2			2	
H5521	197	0	1	04	01	H5521_197_0	3	2	$350 copay	01	10a;		2		2			1	350.00	350.00	2	
H5521	197	0	1	04	01	H5521_197_0	3	3	Supplemental Benefits	11	14d;	14c;16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
H5521	197	0	1	04	01	H5521_197_0	3	4	OON Range preventive	01	14a;		2		1	0	40	2			2	
H5521	197	0	1	04	01	H5521_197_0	3	5	Diabetic services 0%-20%	01	11c;		2		1	0	20	2			2	
H5521	199	0	1	04	01	H5521_199_0	4	1	50 % Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
H5521	199	0	1	04	01	H5521_199_0	4	2	Ambulance $375	01	10a;		2		2			1	375.00	375.00	2	
H5521	199	0	1	04	01	H5521_199_0	4	3	20 % Tier	01	12;		2		1	20	20	2			2	
H5521	199	0	1	04	01	H5521_199_0	4	4	$0 Tier	11	14d;	14c;	2		2			1	0.00	0.00	2	
H5521	199	0	1	04	01	H5521_199_0	4	5	0 - 50% Tier (14A)	01	14a;		2		1	0	50	2			2	
H5521	199	0	1	04	01	H5521_199_0	4	6	11c 0-20%	01	11c;		2		1	0	20	2			2	
H5521	801	0	1	04	01	H5521_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
H5521	801	0	1	04	01	H5521_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5521	802	0	1	04	01	H5521_802_0	2	1		01	6;14a;		2		1	0	0	2			2	
H5521	802	0	1	04	01	H5521_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5521	805	0	2	04	01	H5521_805_0	2	1		01	6;14a;		2		1	0	0	2			2	
H5521	805	0	2	04	01	H5521_805_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5521	806	0	2	04	01	H5521_806_0	2	1		01	6;14a;		2		1	0	0	2			2	
H5521	806	0	2	04	01	H5521_806_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5522	001	0	1	04	01	H5522_001_0	4	1	30% Coinsurance OON	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;12;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		1	30	30	2			2	
H5522	001	0	1	04	01	H5522_001_0	4	10	OTC	10		13b;	1	25.00	2			1	0.00	0.00	2	
H5522	001	0	1	04	01	H5522_001_0	4	2	45% Coinsurance OON	01	5;7e;7h;9c;		2		1	45	45	2			2	
H5522	001	0	1	04	01	H5522_001_0	4	3	$0 Copayment OON	11	6;14d;	14c;17b;	2		2			1	0.00	0.00	2	
H5522	001	0	1	04	01	H5522_001_0	4	4	20% Coinsurance OON	01	11a;11b;14e;		2		1	20	20	2			2	
H5522	001	0	1	04	01	H5522_001_0	4	5	0-20% OON	01	11c;14a;		2		1	0	20	2			2	
H5522	001	0	1	04	01	H5522_001_0	4	6	Hearing Aids 50%	10		18b;	2		1	50	50	2			2	
H5522	001	0	1	04	01	H5522_001_0	4	7	50% Comprehensive Dental (Non Medicare)	10		16b;	2		1	50	50	2			1	100.00
H5522	001	0	1	04	01	H5522_001_0	4	8	30% Preventive Dental (Non Medicare)	10		16a;	2		1	30	30	2			1	100.00
H5522	001	0	1	04	01	H5522_001_0	4	9	$250 Ambulance	01	10a;		2		2			1	250.00	250.00	2	
H5522	002	0	1	04	01	H5522_002_0	5	1	30% Coinsurance OON	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		1	30	30	2			2	
H5522	002	0	1	04	01	H5522_002_0	5	10	OTC	10		13b;	1	15.00	2			1	0.00	0.00	2	
H5522	002	0	1	04	01	H5522_002_0	5	11	Acupuncture	10		13a;	2		2			1	10.00	10.00	2	
H5522	002	0	1	04	01	H5522_002_0	5	2	45% Coinsurance OON	01	5;7e;7h;9c;		2		1	45	45	2			2	
H5522	002	0	1	04	01	H5522_002_0	5	3	0% Coinsurance OON	10		14c;	2		1	0	0	2			2	
H5522	002	0	1	04	01	H5522_002_0	5	4	Preventive Services 0-30%	01	14a;		2		1	0	30	2			2	
H5522	002	0	1	04	01	H5522_002_0	5	5	50% Comprehensive Dental (Non Medicare)	10		16b;	2		1	50	50	2			1	100.00
H5522	002	0	1	04	01	H5522_002_0	5	6	30% Preventive Dental (Non Medicare)	10		16a;	2		1	30	30	2			1	100.00
H5522	002	0	1	04	01	H5522_002_0	5	7	0-20% OON	01	11c;		2		1	0	20	2			2	
H5522	002	0	1	04	01	H5522_002_0	5	8	$0 Copayment OON	11	6;14d;	17b;	2		2			1	0.00	0.00	2	
H5522	002	0	1	04	01	H5522_002_0	5	9	$200 Ambulance	01	10a;		2		2			1	200.00	200.00	2	
H5522	004	0	1	04	01	H5522_004_0	3	1	40% Coinsurance OON	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		1	40	40	2			2	
H5522	004	0	1	04	01	H5522_004_0	3	2	0% Coinsurance OON	10		14c;	2		1	0	0	2			2	
H5522	004	0	1	04	01	H5522_004_0	3	3	45% Coinsurance OON	01	5;7e;7h;9c;		2		1	45	45	2			2	
H5522	004	0	1	04	01	H5522_004_0	3	4	Preventive Services 0-40%	01	14a;		2		1	0	40	2			2	
H5522	004	0	1	04	01	H5522_004_0	3	5	0-20% OON	01	11c;		2		1	0	20	2			2	
H5522	004	0	1	04	01	H5522_004_0	3	6	$0 Copayment OON	01	6;14d;		2		2			1	0.00	0.00	2	
H5522	004	0	1	04	01	H5522_004_0	3	7	$275 Ambulance	01	10a;		2		2			1	275.00	275.00	2	
H5522	005	0	1	04	01	H5522_005_0	4	1	30%	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;11a;11b;12;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		1	30	30	2			2	
H5522	005	0	1	04	01	H5522_005_0	4	2	45%	01	5;7e;7h;9c;		2		1	45	45	2			2	
H5522	005	0	1	04	01	H5522_005_0	4	3	0%	11	14d;	14c;	2		1	0	0	2			2	
H5522	005	0	1	04	01	H5522_005_0	4	4	0-25%	01	14a;		2		1	0	25	2			2	
H5522	005	0	1	04	01	H5522_005_0	4	5	0-20%	01	11c;		2		1	0	20	2			2	
H5522	005	0	1	04	01	H5522_005_0	4	6	25%	01	14e;		2		1	25	25	2			2	
H5522	005	0	1	04	01	H5522_005_0	4	7	$0	01	6;		2		2			1	0.00	0.00	2	
H5522	005	0	1	04	01	H5522_005_0	4	8	$225	01	10a;		2		2			1	225.00	225.00	2	
H5522	013	0	1	04	01	H5522_013_0	3	1	40% Coinsurance OON	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		1	40	40	2			2	
H5522	013	0	1	04	01	H5522_013_0	3	2	45% Coinsurance OON	01	5;7e;7h;9c;		2		1	45	45	2			2	
H5522	013	0	1	04	01	H5522_013_0	3	3	Preventive Services 0-40%	01	14a;		2		1	0	40	2			2	
H5522	013	0	1	04	01	H5522_013_0	3	4	0-20% OON	01	11c;		2		1	0	20	2			2	
H5522	013	0	1	04	01	H5522_013_0	3	5	0% Coinsurance OON	10		14c;	2		1	0	0	2			2	
H5522	013	0	1	04	01	H5522_013_0	3	6	$0 Copayment OON	11	6;14d;	16a;17b;	2		2			1	0.00	0.00	2	
H5522	013	0	1	04	01	H5522_013_0	3	7	$225 Ambulance	01	10a;		2		2			1	225.00	225.00	2	
H5522	014	0	1	04	01	H5522_014_0	4	1	20% Coinsurance OON	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;14e;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		1	20	20	2			2	
H5522	014	0	1	04	01	H5522_014_0	4	10	$225 Ambulance	01	10a;		2		2			1	225.00	225.00	2	
H5522	014	0	1	04	01	H5522_014_0	4	2	30% Coinsurance OON	01	12;		2		1	30	30	2			2	
H5522	014	0	1	04	01	H5522_014_0	4	3	40% Coinsurance OON	01	11a;11b;15;		2		1	40	40	2			2	
H5522	014	0	1	04	01	H5522_014_0	4	4	45% Coinsurance OON	01	5;7e;7h;9c;		2		1	45	45	2			2	
H5522	014	0	1	04	01	H5522_014_0	4	5	0% Coinsurance OON	10		14c;	2		1	0	0	2			2	
H5522	014	0	1	04	01	H5522_014_0	4	6	0-20% OON	01	11c;14a;		2		1	0	20	2			2	
H5522	014	0	1	04	01	H5522_014_0	4	7	50% Comprehensive Dental (Non Medicare)	10		16b;	2		1	50	50	2			1	100.00
H5522	014	0	1	04	01	H5522_014_0	4	8	30% Preventive Dental (Non Medicare)	10		16a;	2		1	30	30	2			1	100.00
H5522	014	0	1	04	01	H5522_014_0	4	9	$0 Copayment OON	11	6;14d;	17b;	2		2			1	0.00	0.00	2	
H5522	017	0	1	04	01	H5522_017_0	3	1	40% Coinsurance OON	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;12;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		1	40	40	2			2	
H5522	017	0	1	04	01	H5522_017_0	3	2	45% Coinsurance OON	01	5;9c;		2		1	45	45	2			2	
H5522	017	0	1	04	01	H5522_017_0	3	3	0% Coinsurance OON	10		14c;	2		1	0	0	2			2	
H5522	017	0	1	04	01	H5522_017_0	3	4	0-20% OON	01	11c;		2		1	0	20	2			2	
H5522	017	0	1	04	01	H5522_017_0	3	5	25% Coinsurance OON	01	11a;11b;		2		1	25	25	2			2	
H5522	017	0	1	04	01	H5522_017_0	3	6	Preventive Services 0-40%	01	14a;		2		1	0	40	2			2	
H5522	017	0	1	04	01	H5522_017_0	3	7	$0 Copayment OON	01	6;14d;		2		2			1	0.00	0.00	2	
H5522	017	0	1	04	01	H5522_017_0	3	8	$325 Ambulance	01	10a;		2		2			1	325.00	325.00	2	
H5522	018	0	1	04	01	H5522_018_0	3	1	40% Coinsurance OON	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;12;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		1	40	40	2			2	
H5522	018	0	1	04	01	H5522_018_0	3	2	45% Coinsurance OON	01	5;7e;7h;9c;		2		1	45	45	2			2	
H5522	018	0	1	04	01	H5522_018_0	3	3	0% Coinsurance OON	10		14c;	2		1	0	0	2			2	
H5522	018	0	1	04	01	H5522_018_0	3	4	25% Coinsurance OON	01	11a;11b;		2		1	25	25	2			2	
H5522	018	0	1	04	01	H5522_018_0	3	5	0-20% OON	01	11c;		2		1	0	20	2			2	
H5522	018	0	1	04	01	H5522_018_0	3	6	Preventive Services 0-40%	01	14a;		2		1	0	40	2			2	
H5522	018	0	1	04	01	H5522_018_0	3	7	$0 Copayment OON	01	6;14d;		2		2			1	0.00	0.00	2	
H5522	018	0	1	04	01	H5522_018_0	3	8	$275 Ambulance	01	10a;		2		2			1	275.00	275.00	2	
H5522	018	0	1	04	01	H5522_018_0	3	9	OTC	10		13b;	1	25.00	2			1	0.00	0.00	2	
H5522	802	0	1	04	01	H5522_802_0	1	1		01	6;14a;		2		1	0	0	2			2	
H5522	802	0	1	04	01	H5522_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5522	803	0	1	04	01	H5522_803_0	1	1		01	6;14a;		2		1	0	0	2			2	
H5522	803	0	1	04	01	H5522_803_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5525	004	0	1	04	01	H5525_004_0	5	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H5525	004	0	1	04	01	H5525_004_0	5	2		10		18a;	2		2			1	35.00	35.00	2	
H5525	004	0	1	04	01	H5525_004_0	5	3		01	12;		2		1	20	20	2			2	
H5525	004	0	1	04	01	H5525_004_0	5	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5525	004	0	1	04	01	H5525_004_0	5	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;13c;14b;14c;16a;	2		1	50	50	2			2	
H5525	004	0	1	04	01	H5525_004_0	5	6		10		13b;	1	20.00	1	50	50	2			2	
H5525	004	0	1	04	01	H5525_004_0	5	7		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5525	005	0	1	04	01	H5525_005_0	3	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5525	005	0	1	04	01	H5525_005_0	3	2		10		18b;	2		2			1	499.00	799.00	2	
H5525	005	0	1	04	01	H5525_005_0	3	3		01	11a;12;		2		1	20	20	2			2	
H5525	005	0	1	04	01	H5525_005_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5525	005	0	1	04	01	H5525_005_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5525	005	0	1	04	01	H5525_005_0	3	6		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5525	005	0	1	04	01	H5525_005_0	3	7		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5525	005	0	1	04	01	H5525_005_0	3	8		10		13b;	1	45.00	1	50	50	2			2	
H5525	006	0	1	04	01	H5525_006_0	3	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5525	006	0	1	04	01	H5525_006_0	3	2		10		18b;	2		2			1	499.00	799.00	2	
H5525	006	0	1	04	01	H5525_006_0	3	3		01	11a;12;		2		1	20	20	2			2	
H5525	006	0	1	04	01	H5525_006_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5525	006	0	1	04	01	H5525_006_0	3	5		01	15;		2		1	20	30	2			2	
H5525	006	0	1	04	01	H5525_006_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5525	006	0	1	04	01	H5525_006_0	3	7		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5525	006	0	1	04	01	H5525_006_0	3	8		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5525	006	0	1	04	01	H5525_006_0	3	9		10		13b;	1	45.00	1	50	50	2			2	
H5525	007	0	1	04	01	H5525_007_0	3	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5525	007	0	1	04	01	H5525_007_0	3	2		10		18b;	2		2			1	499.00	799.00	2	
H5525	007	0	1	04	01	H5525_007_0	3	3		01	11a;12;		2		1	20	20	2			2	
H5525	007	0	1	04	01	H5525_007_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5525	007	0	1	04	01	H5525_007_0	3	5		01	15;		2		1	20	30	2			2	
H5525	007	0	1	04	01	H5525_007_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5525	007	0	1	04	01	H5525_007_0	3	7		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5525	007	0	1	04	01	H5525_007_0	3	8		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5525	007	0	1	04	01	H5525_007_0	3	9		10		13b;	1	45.00	1	50	50	2			2	
H5525	008	0	1	04	01	H5525_008_0	3	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5525	008	0	1	04	01	H5525_008_0	3	2		01	12;		2		1	20	20	2			2	
H5525	008	0	1	04	01	H5525_008_0	3	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5525	008	0	1	04	01	H5525_008_0	3	4		01	15;		2		1	20	50	2			2	
H5525	008	0	1	04	01	H5525_008_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;16b;17a;18a;	13c;14b;14c;16a;16b;	2		1	50	50	2			2	
H5525	008	0	1	04	01	H5525_008_0	3	6		10		13b;	1	10.00	1	50	50	2			2	
H5525	008	0	1	04	01	H5525_008_0	3	7		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5525	015	0	1	04	01	H5525_015_0	3	1		11	9d;17b;	9d;17a;18a;	2		2			1	0.00	0.00	2	
H5525	015	0	1	04	01	H5525_015_0	3	10		10		13b;	1	25.00	1	50	50	2			2	
H5525	015	0	1	04	01	H5525_015_0	3	2		10		18b;	2		2			1	699.00	999.00	2	
H5525	015	0	1	04	01	H5525_015_0	3	3		01	12;		2		1	20	20	2			2	
H5525	015	0	1	04	01	H5525_015_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5525	015	0	1	04	01	H5525_015_0	3	5		01	11a;		2		1	22	22	2			2	
H5525	015	0	1	04	01	H5525_015_0	3	6		01	11c;		2		1	25	25	2			2	
H5525	015	0	1	04	01	H5525_015_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5525	015	0	1	04	01	H5525_015_0	3	8		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5525	015	0	1	04	01	H5525_015_0	3	9		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5525	017	0	1	04	01	H5525_017_0	3	1		11	9d;17b;	9d;17a;18a;	2		2			1	0.00	0.00	2	
H5525	017	0	1	04	01	H5525_017_0	3	2		10		18b;	2		2			1	499.00	799.00	2	
H5525	017	0	1	04	01	H5525_017_0	3	3		01	12;		2		1	20	20	2			2	
H5525	017	0	1	04	01	H5525_017_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5525	017	0	1	04	01	H5525_017_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5525	017	0	1	04	01	H5525_017_0	3	6		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5525	017	0	1	04	01	H5525_017_0	3	7		10		13c;14c;16a;	2		1	50	50	2			2	
H5525	017	0	1	04	01	H5525_017_0	3	8		10		13b;	1	45.00	1	50	50	2			2	
H5525	020	0	1	04	01	H5525_020_0	2	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H5525	020	0	1	04	01	H5525_020_0	2	2		01	11a;11c;12;		2		1	20	20	2			2	
H5525	020	0	1	04	01	H5525_020_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5525	020	0	1	04	01	H5525_020_0	2	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5525	020	0	1	04	01	H5525_020_0	2	5		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5525	020	0	1	04	01	H5525_020_0	2	6		10		13c;14c;	2		1	50	50	2			2	
H5525	020	0	1	04	01	H5525_020_0	2	7		10		13b;	1	30.00	1	50	50	2			2	
H5525	022	0	1	04	01	H5525_022_0	3	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5525	022	0	1	04	01	H5525_022_0	3	2		10		18b;	2		2			1	499.00	799.00	2	
H5525	022	0	1	04	01	H5525_022_0	3	3		01	12;		2		1	20	20	2			2	
H5525	022	0	1	04	01	H5525_022_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5525	022	0	1	04	01	H5525_022_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5525	022	0	1	04	01	H5525_022_0	3	6		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5525	022	0	1	04	01	H5525_022_0	3	7		10		13c;14c;	2		1	50	50	2			2	
H5525	022	0	1	04	01	H5525_022_0	3	8		10		13b;	1	45.00	1	50	50	2			2	
H5525	023	0	1	04	01	H5525_023_0	3	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5525	023	0	1	04	01	H5525_023_0	3	2		10		18b;	2		2			1	499.00	799.00	2	
H5525	023	0	1	04	01	H5525_023_0	3	3		01	12;		2		1	20	20	2			2	
H5525	023	0	1	04	01	H5525_023_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5525	023	0	1	04	01	H5525_023_0	3	5		01	15;		2		1	20	30	2			2	
H5525	023	0	1	04	01	H5525_023_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5525	023	0	1	04	01	H5525_023_0	3	7		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5525	023	0	1	04	01	H5525_023_0	3	8		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5525	023	0	1	04	01	H5525_023_0	3	9		10		13b;	1	45.00	1	50	50	2			2	
H5525	024	0	1	04	01	H5525_024_0	5	1		11	9d;17b;	9d;18a;	2		2			1	0.00	0.00	2	
H5525	024	0	1	04	01	H5525_024_0	5	2		10		18b;	2		2			1	699.00	999.00	2	
H5525	024	0	1	04	01	H5525_024_0	5	3		01	12;		2		1	20	20	2			2	
H5525	024	0	1	04	01	H5525_024_0	5	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5525	024	0	1	04	01	H5525_024_0	5	5		01	11a;11b;11c;		2		1	25	25	2			2	
H5525	024	0	1	04	01	H5525_024_0	5	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5525	024	0	1	04	01	H5525_024_0	5	7		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5525	024	0	1	04	01	H5525_024_0	5	8		10		13c;14c;	2		1	50	50	2			2	
H5525	024	0	1	04	01	H5525_024_0	5	9		10		13b;	1	25.00	1	50	50	2			2	
H5525	025	0	1	04	01	H5525_025_0	6	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5525	025	0	1	04	01	H5525_025_0	6	2		10		18b;	2		2			1	699.00	999.00	2	
H5525	025	0	1	04	01	H5525_025_0	6	3		01	12;		2		1	20	20	2			2	
H5525	025	0	1	04	01	H5525_025_0	6	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5525	025	0	1	04	01	H5525_025_0	6	5		01	11a;11b;11c;		2		1	25	25	2			2	
H5525	025	0	1	04	01	H5525_025_0	6	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5525	025	0	1	04	01	H5525_025_0	6	7		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5525	025	0	1	04	01	H5525_025_0	6	8		10		13c;14c;	2		1	50	50	2			2	
H5525	025	0	1	04	01	H5525_025_0	6	9		10		13b;	1	25.00	1	50	50	2			2	
H5525	026	0	1	04	01	H5525_026_0	5	1		11	9d;17b;	9d;18a;	2		2			1	0.00	0.00	2	
H5525	026	0	1	04	01	H5525_026_0	5	2		10		18b;	2		2			1	699.00	999.00	2	
H5525	026	0	1	04	01	H5525_026_0	5	3		01	11a;12;		2		1	20	20	2			2	
H5525	026	0	1	04	01	H5525_026_0	5	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5525	026	0	1	04	01	H5525_026_0	5	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	14b;	2		1	35	35	2			2	
H5525	026	0	1	04	01	H5525_026_0	5	6		01	14a;		2		1	35	35	1	0.00	0.00	2	
H5525	026	0	1	04	01	H5525_026_0	5	7		10		13c;14c;	2		1	50	50	2			2	
H5525	026	0	1	04	01	H5525_026_0	5	8		10		13b;	1	30.00	1	50	50	2			2	
H5525	027	0	1	04	01	H5525_027_0	3	1		11	9d;	9d;	2		2			1	0.00	0.00	2	
H5525	027	0	1	04	01	H5525_027_0	3	2		01	11a;12;		2		1	20	20	2			2	
H5525	027	0	1	04	01	H5525_027_0	3	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5525	027	0	1	04	01	H5525_027_0	3	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;14b;14c;	2		1	50	50	2			2	
H5525	027	0	1	04	01	H5525_027_0	3	5		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5525	030	0	1	04	01	H5525_030_0	6	1		11	6;8a1;8a2;9d;14a;14d;14e;17a;17b;	9d;14b;17a;17b;18a;	2		2			1	0.00	90.00	2	
H5525	030	0	1	04	01	H5525_030_0	6	10		01	11c;		2		1	10	20	1	10.00	10.00	2	
H5525	030	0	1	04	01	H5525_030_0	6	11		01	11a;11b;12;15;		2		1	20	20	2			2	
H5525	030	0	1	04	01	H5525_030_0	6	12		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5525	030	0	1	04	01	H5525_030_0	6	13		01	8b2;		2		1	20	20	1	30.00	30.00	2	
H5525	030	0	1	04	01	H5525_030_0	6	14		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5525	030	0	1	04	01	H5525_030_0	6	15		10		13b;	1	30.00	1	50	50	2			2	
H5525	030	0	1	04	01	H5525_030_0	6	2		01	3-1;3-2;3-3;7c;7i;		2		2			1	10.00	40.00	2	
H5525	030	0	1	04	01	H5525_030_0	6	3		01	7b;		2		2			1	20.00	20.00	2	
H5525	030	0	1	04	01	H5525_030_0	6	4		01	9b;		2		2			1	220.00	220.00	2	
H5525	030	0	1	04	01	H5525_030_0	6	5		01	9a;		2		2			1	250.00	250.00	2	
H5525	030	0	1	04	01	H5525_030_0	6	6		01	8b1;		2		2			1	30.00	250.00	2	
H5525	030	0	1	04	01	H5525_030_0	6	7		01	5;7d;7e;7f;7h;9c;16b;18a;		2		2			1	30.00	90.00	2	
H5525	030	0	1	04	01	H5525_030_0	6	8		01	7a;7g;8b3;		2		2			1	5.00	95.00	2	
H5525	030	0	1	04	01	H5525_030_0	6	9		10		18b;	2		2			1	699.00	999.00	2	
H5525	031	0	1	04	01	H5525_031_0	2	1		11	9d;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
H5525	031	0	1	04	01	H5525_031_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
H5525	031	0	1	04	01	H5525_031_0	2	3		01	11a;		2		1	10	10	2			2	
H5525	031	0	1	04	01	H5525_031_0	2	4		01	12;		2		1	20	20	2			2	
H5525	031	0	1	04	01	H5525_031_0	2	5		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5525	031	0	1	04	01	H5525_031_0	2	6		01	11c;		2		1	20	50	2			2	
H5525	031	0	1	04	01	H5525_031_0	2	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;15;16b;17a;17b;18a;	13c;14b;14c;16a;16b;	2		1	50	50	2			2	
H5525	031	0	1	04	01	H5525_031_0	2	8		10		13b;	1	75.00	1	50	50	2			2	
H5525	031	0	1	04	01	H5525_031_0	2	9		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5525	809	0	1	04	01	H5525_809_0	4	1		01	6;14a;		2		1	0	0	2			2	
H5525	809	0	1	04	01	H5525_809_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5525	810	0	1	04	01	H5525_810_0	4	1		01	6;14a;		2		1	0	0	2			2	
H5525	810	0	1	04	01	H5525_810_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5525	811	0	1	04	01	H5525_811_0	4	1		01	6;14a;		2		1	0	0	2			2	
H5525	811	0	1	04	01	H5525_811_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5525	812	0	2	04	01	H5525_812_0	4	1		01	6;14a;		2		1	0	0	2			2	
H5525	812	0	2	04	01	H5525_812_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5525	813	0	2	04	01	H5525_813_0	4	1		01	6;14a;		2		1	0	0	2			2	
H5525	813	0	2	04	01	H5525_813_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5525	814	0	2	04	01	H5525_814_0	4	1		01	6;14a;		2		1	0	0	2			2	
H5525	814	0	2	04	01	H5525_814_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5526	004	0	1	04	01	H5526_004_0	3	1	50% Group	01	5;7e;7h;9c;11a;11b;11c;		2		1	50	50	2			2	
H5526	004	0	1	04	01	H5526_004_0	3	2	25% Group	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;14a;14d;14e;15;16b;17a;17b;18a;	7f;9d;14b;14c;17a;	2		1	25	25	2			2	
H5526	004	0	1	04	01	H5526_004_0	3	3	Renal Dialysis	01	12;		2		1	20	20	1	20.00	20.00	2	
H5526	004	0	1	04	01	H5526_004_0	3	4	Ambulance	01	10a;		2		2			1	200.00	200.00	2	
H5526	004	0	1	04	01	H5526_004_0	3	5	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H5526	004	0	1	04	01	H5526_004_0	3	6	Hearing Exam	10		18a;	2		2			1	45.00	45.00	2	
H5526	004	0	1	04	01	H5526_004_0	3	7	Eyewear	10		17b;	2		2			2			2	
H5526	016	0	1	04	01	H5526_016_0	4	1	50% Group	01	5;7e;7h;9c;11a;11b;11c;		2		1	50	50	2			2	
H5526	016	0	1	04	01	H5526_016_0	4	2	35% Group	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;14a;14d;14e;15;16b;17a;17b;18a;	7f;9d;14b;14c;17a;	2		1	35	35	2			2	
H5526	016	0	1	04	01	H5526_016_0	4	3	Renal Dialysis	01	12;		2		1	20	20	1	30.00	30.00	2	
H5526	016	0	1	04	01	H5526_016_0	4	4	Ambulance	01	10a;		2		2			1	250.00	250.00	2	
H5526	016	0	1	04	01	H5526_016_0	4	5	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H5526	016	0	1	04	01	H5526_016_0	4	6	Hearing Exam	10		18a;	2		2			1	45.00	45.00	2	
H5526	016	0	1	04	01	H5526_016_0	4	7	Eyewear	10		17b;	2		2			2			2	
H5526	017	0	1	04	01	H5526_017_0	3	1	50% Group	01	5;7e;7h;9c;11a;11b;11c;		2		1	50	50	2			2	
H5526	017	0	1	04	01	H5526_017_0	3	2	35% Group	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;14a;14d;14e;15;16b;17a;17b;18a;	7f;9d;14b;14c;17a;	2		1	35	35	2			2	
H5526	017	0	1	04	01	H5526_017_0	3	3	Renal Dialysis	01	12;		2		1	20	20	1	30.00	30.00	2	
H5526	017	0	1	04	01	H5526_017_0	3	4	Ambulance	01	10a;		2		2			1	200.00	200.00	2	
H5526	017	0	1	04	01	H5526_017_0	3	5	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H5526	017	0	1	04	01	H5526_017_0	3	6	Hearing Exams	10		18a;	2		2			1	45.00	45.00	2	
H5526	018	0	1	04	01	H5526_018_0	3	1	50% Group	01	5;7e;7h;9c;11a;11b;11c;		2		1	50	50	2			2	
H5526	018	0	1	04	01	H5526_018_0	3	2	25% Group	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;14a;14d;14e;15;16b;17a;17b;18a;	7f;9d;14b;14c;17a;	2		1	25	25	2			2	
H5526	018	0	1	04	01	H5526_018_0	3	3	Renal Dialysis	01	12;		2		1	20	20	1	20.00	20.00	2	
H5526	018	0	1	04	01	H5526_018_0	3	4	Ambulance	01	10a;		2		2			1	150.00	150.00	2	
H5526	018	0	1	04	01	H5526_018_0	3	5	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H5526	018	0	1	04	01	H5526_018_0	3	6	Hearing Exams	10		18a;	2		2			1	45.00	45.00	2	
H5526	018	0	1	04	01	H5526_018_0	3	7	Eyewear	10		17b;	2		2			2			2	
H5526	019	0	1	04	01	H5526_019_0	3	1	35% Group	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;14a;14d;14e;15;16b;17a;17b;18a;	7f;9d;14b;14c;17a;	2		1	35	35	2			2	
H5526	019	0	1	04	01	H5526_019_0	3	2	50% Group	01	5;7e;7h;9c;11a;11b;11c;		2		1	50	50	2			2	
H5526	019	0	1	04	01	H5526_019_0	3	3	Ambulance	01	10a;		2		2			1	250.00	250.00	2	
H5526	019	0	1	04	01	H5526_019_0	3	4	Dialysis	01	12;		2		1	20	20	2			2	
H5526	019	0	1	04	01	H5526_019_0	3	5	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H5526	019	0	1	04	01	H5526_019_0	3	6	Hearing Exams	10		18a;	2		2			1	45.00	45.00	2	
H5526	019	0	1	04	01	H5526_019_0	3	7	Eyewear	10		17b;	2		2			2			2	
H5526	806	0	1	04	01	H5526_806_0	2	1		01	6;14a;		2		1	0	0	2			2	
H5526	806	0	1	04	01	H5526_806_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5526	808	0	1	04	01	H5526_808_0	2	1		01	6;14a;		2		1	0	0	2			2	
H5526	808	0	1	04	01	H5526_808_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5528	807	0	1	04	01	H5528_807_0	1	1	20%	01	3-1;3-2;3-3;5;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5528	807	0	1	04	01	H5528_807_0	1	2	40%	01	7e;7h;		2		1	40	40	2			2	
H5528	807	0	1	04	01	H5528_807_0	1	3	0%	01	6;14a;		2		1	0	0	2			2	
H5533	003	0	1	04	01	H5533_003_0	5	1	30% Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;12;14a;14d;14e;16b;17a;17b;18a;	7b;7f;9d;14b;	2		1	30	30	2			2	
H5533	003	0	1	04	01	H5533_003_0	5	2	$40 OON Copay	01	7a;		2		2			1	40.00	40.00	2	
H5533	003	0	1	04	01	H5533_003_0	5	3	$60 OON Copay	11	7d;7g;	17a;	2		2			1	60.00	60.00	2	
H5533	003	0	1	04	01	H5533_003_0	5	4	OON Routine Vision	10		17b;	2		2			2			2	
H5533	003	0	1	04	01	H5533_003_0	5	5	50% OON	11	11a;11b;11c;15;	14c;16a;	2		1	50	50	2			2	
H5533	005	0	1	04	01	H5533_005_0	5	1	30% OON coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;12;14a;14d;14e;15;16b;17a;17b;18a;	7b;7f;9d;14b;18a;	2		1	30	30	2			2	
H5533	005	0	1	04	01	H5533_005_0	5	2	$30 OON Copay	01	7a;		2		2			1	30.00	30.00	2	
H5533	005	0	1	04	01	H5533_005_0	5	3	$50 OON Copay	11	7d;7g;	17a;	2		2			1	50.00	50.00	2	
H5533	005	0	1	04	01	H5533_005_0	5	4	50% OON	11	11a;11b;11c;	14c;16a;	2		1	50	50	2			2	
H5533	005	0	1	04	01	H5533_005_0	5	5	OON Benefit Allowance	10		17b;18b;	2		2			2			2	
H5533	007	0	1	04	01	H5533_007_0	8	1	30% OON coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;12;14a;14d;14e;15;16b;17a;17b;18a;	7b;7f;9d;14b;18a;	2		1	30	30	2			2	
H5533	007	0	1	04	01	H5533_007_0	8	2	$30 OON Copay	01	7a;		2		2			1	30.00	30.00	2	
H5533	007	0	1	04	01	H5533_007_0	8	3	$50 OON Copay	11	7d;7g;	17a;	2		2			1	50.00	50.00	2	
H5533	007	0	1	04	01	H5533_007_0	8	4	50% OON	11	11a;11b;11c;	14c;16a;	2		1	50	50	2			2	
H5533	007	0	1	04	01	H5533_007_0	8	5	OON Benefit Allowance	10		17b;18b;	2		2			2			2	
H5533	008	0	1	04	01	H5533_008_0	7	1	30% OON coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;12;14a;14d;14e;15;16b;17a;17b;18a;	7b;7f;9d;14b;18a;	2		1	30	30	2			2	
H5533	008	0	1	04	01	H5533_008_0	7	2	$30 OON Copay	01	7a;		2		2			1	30.00	30.00	2	
H5533	008	0	1	04	01	H5533_008_0	7	3	$50 OON Copay	11	7d;7g;	17a;	2		2			1	50.00	50.00	2	
H5533	008	0	1	04	01	H5533_008_0	7	4	50% OON	11	11a;11b;11c;	14c;16a;	2		1	50	50	2			2	
H5533	008	0	1	04	01	H5533_008_0	7	5	OON Benefit Allowance	10		17b;18b;	2		2			2			2	
H5533	801	0	1	04	01	H5533_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
H5533	801	0	1	04	01	H5533_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5533	802	0	1	04	01	H5533_802_0	2	1		01	6;14a;		2		1	0	0	2			2	
H5533	802	0	1	04	01	H5533_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5533	803	0	1	04	01	H5533_803_0	2	1		01	6;14a;		2		1	0	0	2			2	
H5533	803	0	1	04	01	H5533_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5619	001	0	1	01	01	H5619_001_0	3	1														
H5619	003	0	1	01	01	H5619_003_0	4	1														
H5619	012	0	1	01	01	H5619_012_0	2	1														
H5619	013	0	1	01	01	H5619_013_0	2	1														
H5619	015	0	1	01	01	H5619_015_0	2	1														
H5619	016	0	1	01	01	H5619_016_0	2	1														
H5619	021	0	1	01	01	H5619_021_0	2	1														
H5619	023	0	1	01	01	H5619_023_0	2	1														
H5619	026	0	1	01	01	H5619_026_0	2	1														
H5619	029	0	1	01	01	H5619_029_0	2	1														
H5619	032	0	1	01	01	H5619_032_0	2	1														
H5619	037	0	1	01	01	H5619_037_0	2	1														
H5619	038	0	1	01	01	H5619_038_0	3	1														
H5619	039	1	1	01	01	H5619_039_1	2	1														
H5619	039	2	1	01	01	H5619_039_2	2	1														
H5619	040	1	1	01	01	H5619_040_1	3	1														
H5619	040	2	1	01	01	H5619_040_2	3	1														
H5619	040	3	1	01	01	H5619_040_3	3	1														
H5619	041	0	1	01	01	H5619_041_0	3	1														
H5619	042	1	1	01	01	H5619_042_1	2	1														
H5619	042	2	1	01	01	H5619_042_2	2	1														
H5619	044	0	1	01	01	H5619_044_0	2	1														
H5619	045	0	1	01	01	H5619_045_0	2	1														
H5619	046	0	1	01	01	H5619_046_0	3	1														
H5619	047	0	1	01	01	H5619_047_0	2	1														
H5619	049	0	1	01	01	H5619_049_0	4	1														
H5619	050	0	1	01	01	H5619_050_0	3	1														
H5619	051	0	1	01	01	H5619_051_0	3	1														
H5619	052	0	1	01	01	H5619_052_0	3	1														
H5619	053	0	1	01	01	H5619_053_0	3	1														
H5619	054	0	1	01	01	H5619_054_0	3	1														
H5619	055	0	1	01	01	H5619_055_0	4	1														
H5619	056	0	1	01	01	H5619_056_0	4	1														
H5619	057	0	1	01	01	H5619_057_0	4	1														
H5619	059	0	1	01	01	H5619_059_0	4	1														
H5619	060	0	1	01	01	H5619_060_0	4	1														
H5619	061	0	1	01	01	H5619_061_0	4	1														
H5619	062	0	1	01	01	H5619_062_0	4	1														
H5619	063	0	1	01	01	H5619_063_0	4	1														
H5619	064	0	1	01	01	H5619_064_0	4	1														
H5619	065	0	1	01	01	H5619_065_0	2	1														
H5619	066	0	1	01	01	H5619_066_0	5	1														
H5619	067	0	1	01	01	H5619_067_0	4	1														
H5619	069	0	1	01	01	H5619_069_0	3	1														
H5619	070	1	1	01	01	H5619_070_1	2	1														
H5619	070	2	1	01	01	H5619_070_2	2	1														
H5619	071	0	1	01	01	H5619_071_0	2	1														
H5619	072	0	1	01	01	H5619_072_0	2	1														
H5619	073	0	1	01	01	H5619_073_0	2	1														
H5619	074	1	1	01	01	H5619_074_1	2	1														
H5619	074	2	1	01	01	H5619_074_2	2	1														
H5619	075	0	1	01	01	H5619_075_0	4	1														
H5619	076	0	1	01	01	H5619_076_0	4	1														
H5619	077	0	1	01	01	H5619_077_0	4	1														
H5619	078	0	1	01	01	H5619_078_0	4	1														
H5619	079	0	1	01	01	H5619_079_0	4	1														
H5619	080	0	1	01	01	H5619_080_0	3	1														
H5619	081	0	1	01	01	H5619_081_0	2	1														
H5619	082	0	1	01	01	H5619_082_0	3	1														
H5619	083	0	1	01	01	H5619_083_0	2	1														
H5619	084	0	1	01	01	H5619_084_0	2	1														
H5619	086	0	1	01	01	H5619_086_0	3	1														
H5619	087	0	1	01	01	H5619_087_0	4	1														
H5619	088	0	1	01	01	H5619_088_0	2	1														
H5619	089	0	1	01	01	H5619_089_0	2	1														
H5619	090	0	1	01	01	H5619_090_0	2	1														
H5619	091	0	1	01	01	H5619_091_0	2	1														
H5619	093	0	1	01	01	H5619_093_0	5	1														
H5619	094	0	1	01	01	H5619_094_0	2	1														
H5619	095	0	1	01	01	H5619_095_0	2	1														
H5619	096	1	1	01	01	H5619_096_1	2	1														
H5619	096	2	1	01	01	H5619_096_2	2	1														
H5619	097	0	1	01	01	H5619_097_0	4	1														
H5619	099	0	1	01	01	H5619_099_0	4	1														
H5619	100	0	1	01	01	H5619_100_0	4	1														
H5619	101	0	1	01	01	H5619_101_0	4	1														
H5619	102	0	1	01	01	H5619_102_0	4	1														
H5619	104	0	1	01	01	H5619_104_0	4	1														
H5619	109	0	1	01	01	H5619_109_0	2	1														
H5959	001	0	1	04	01	H5959_001_0	6	1	Out of Network Medicare covered	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;		2		1	40	40	2			2	
H5959	001	0	1	04	01	H5959_001_0	6	2	OON 9d, 14b, 14c	10		9d;14b;14c;	2		1	40	40	2			2	
H5959	001	0	1	04	01	H5959_001_0	6	3	OON 18b Hearing Exams & Aids	10		18b;	2		2			1	699.00	999.00	2	
H5959	001	0	1	04	01	H5959_001_0	6	4	OON 18a Hearing Exams	10		18a;	2		2			1	45.00	45.00	2	
H5959	003	0	1	04	01	H5959_003_0	6	1	Out of Network Medicare covered	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;		2		1	40	40	2			2	
H5959	003	0	1	04	01	H5959_003_0	6	2	OON 9d, 14b, 14c, 17a	10		9d;14b;14c;17a;	2		1	40	40	2			2	
H5959	003	0	1	04	01	H5959_003_0	6	3	OON 18b Heating aids	10		18b;	2		2			1	699.00	999.00	2	
H5959	003	0	1	04	01	H5959_003_0	6	4	OON 17b Eyewear	10		17b;	2		2			2			2	
H5959	003	0	1	04	01	H5959_003_0	6	5	18a Hearing Exams	10		18a;	2		2			1	45.00	45.00	2	
H5970	001	0	1	04	01	H5970_001_0	3	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H5970	001	0	1	04	01	H5970_001_0	3	10		01	3-1;3-2;3-3;7c;7i;9c;		2		1	30	30	1	60.00	60.00	2	
H5970	001	0	1	04	01	H5970_001_0	3	11		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H5970	001	0	1	04	01	H5970_001_0	3	12		10		13b;	1	45.00	1	50	50	2			2	
H5970	001	0	1	04	01	H5970_001_0	3	2		11	7a;	14b;	2		2			1	30.00	30.00	2	
H5970	001	0	1	04	01	H5970_001_0	3	3		01	14d;		2		2			1	30.00	60.00	2	
H5970	001	0	1	04	01	H5970_001_0	3	4		01	7b;7d;7e;7f;7g;7h;16b;17a;18a;		2		2			1	60.00	60.00	2	
H5970	001	0	1	04	01	H5970_001_0	3	5		01	8b2;11a;11b;12;		2		1	20	20	2			2	
H5970	001	0	1	04	01	H5970_001_0	3	6		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5970	001	0	1	04	01	H5970_001_0	3	7		01	5;6;9a;9b;11c;15;		2		1	30	30	2			2	
H5970	001	0	1	04	01	H5970_001_0	3	8		01	14a;		2		1	30	30	1	0.00	60.00	2	
H5970	001	0	1	04	01	H5970_001_0	3	9		01	8a1;8a2;8b1;8b3;14e;		2		1	30	30	1	30.00	60.00	2	
H5970	008	0	1	04	01	H5970_008_0	4	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5970	008	0	1	04	01	H5970_008_0	4	10		01	3-1;3-2;3-3;7c;7i;9c;		2		1	20	20	1	60.00	60.00	2	
H5970	008	0	1	04	01	H5970_008_0	4	11		10		18a;18b;	2		1	25	25	2			2	
H5970	008	0	1	04	01	H5970_008_0	4	12		10		13c;14c;	2		1	50	50	2			2	
H5970	008	0	1	04	01	H5970_008_0	4	13		10		13b;	1	25.00	1	50	50	2			2	
H5970	008	0	1	04	01	H5970_008_0	4	14		10		16b;	2		1	50	70	2			2	
H5970	008	0	1	04	01	H5970_008_0	4	2		11	7a;	14b;	2		2			1	25.00	25.00	2	
H5970	008	0	1	04	01	H5970_008_0	4	3		01	14d;		2		2			1	25.00	60.00	2	
H5970	008	0	1	04	01	H5970_008_0	4	4		01	7b;7d;7e;7f;7g;7h;16b;17a;18a;		2		2			1	60.00	60.00	2	
H5970	008	0	1	04	01	H5970_008_0	4	5		10		16a;	2		1	0	0	2			2	
H5970	008	0	1	04	01	H5970_008_0	4	6		01	5;6;8b2;9a;9b;11a;11b;11c;12;15;		2		1	20	20	2			2	
H5970	008	0	1	04	01	H5970_008_0	4	7		01	14a;		2		1	20	20	1	0.00	60.00	2	
H5970	008	0	1	04	01	H5970_008_0	4	8		01	8a1;8a2;8b1;8b3;14e;		2		1	20	20	1	25.00	60.00	2	
H5970	008	0	1	04	01	H5970_008_0	4	9		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5970	015	0	1	04	01	H5970_015_0	3	1		11	9d;17b;	9d;	2		2			1	0.00	0.00	2	
H5970	015	0	1	04	01	H5970_015_0	3	10		01	3-1;3-2;3-3;7c;7i;9c;		2		1	30	30	1	70.00	70.00	2	
H5970	015	0	1	04	01	H5970_015_0	3	11		10		13c;14c;	2		1	50	50	2			2	
H5970	015	0	1	04	01	H5970_015_0	3	2		11	7a;	14b;	2		2			1	40.00	40.00	2	
H5970	015	0	1	04	01	H5970_015_0	3	3		01	14d;		2		2			1	40.00	70.00	2	
H5970	015	0	1	04	01	H5970_015_0	3	4		01	7b;7d;7e;7f;7g;7h;16b;17a;18a;		2		2			1	70.00	70.00	2	
H5970	015	0	1	04	01	H5970_015_0	3	5		01	8b2;12;		2		1	20	20	2			2	
H5970	015	0	1	04	01	H5970_015_0	3	6		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5970	015	0	1	04	01	H5970_015_0	3	7		01	5;6;9a;9b;11a;11b;11c;15;		2		1	30	30	2			2	
H5970	015	0	1	04	01	H5970_015_0	3	8		01	14a;		2		1	30	30	1	0.00	70.00	2	
H5970	015	0	1	04	01	H5970_015_0	3	9		01	8a1;8a2;8b1;8b3;14e;		2		1	30	30	1	40.00	70.00	2	
H5970	016	0	1	04	01	H5970_016_0	2	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
H5970	016	0	1	04	01	H5970_016_0	2	2		10		16a;	2		1	0	0	2			2	
H5970	016	0	1	04	01	H5970_016_0	2	3		01	8b2;11a;12;		2		1	20	20	2			2	
H5970	016	0	1	04	01	H5970_016_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5970	016	0	1	04	01	H5970_016_0	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
H5970	016	0	1	04	01	H5970_016_0	2	6		01	14a;		2		1	30	30	1	0.00	0.00	2	
H5970	016	0	1	04	01	H5970_016_0	2	7		10		13c;14c;	2		1	50	50	2			2	
H5970	016	0	1	04	01	H5970_016_0	2	8		10		13b;	1	45.00	1	50	50	2			2	
H5970	016	0	1	04	01	H5970_016_0	2	9		10		16b;	2		1	50	70	2			2	
H5970	017	0	1	04	01	H5970_017_0	3	1		11	9d;17b;	9d;	2		2			1	0.00	0.00	2	
H5970	017	0	1	04	01	H5970_017_0	3	10		01	3-1;3-2;3-3;7c;7i;9c;		2		1	30	30	1	70.00	70.00	2	
H5970	017	0	1	04	01	H5970_017_0	3	11		10		13c;14c;	2		1	50	50	2			2	
H5970	017	0	1	04	01	H5970_017_0	3	2		11	7a;	14b;	2		2			1	40.00	40.00	2	
H5970	017	0	1	04	01	H5970_017_0	3	3		01	14d;		2		2			1	40.00	70.00	2	
H5970	017	0	1	04	01	H5970_017_0	3	4		01	7b;7d;7e;7f;7g;7h;16b;17a;18a;		2		2			1	70.00	70.00	2	
H5970	017	0	1	04	01	H5970_017_0	3	5		01	8b2;12;		2		1	20	20	2			2	
H5970	017	0	1	04	01	H5970_017_0	3	6		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5970	017	0	1	04	01	H5970_017_0	3	7		01	5;6;9a;9b;11a;11b;11c;15;		2		1	30	30	2			2	
H5970	017	0	1	04	01	H5970_017_0	3	8		01	14a;		2		1	30	30	1	0.00	70.00	2	
H5970	017	0	1	04	01	H5970_017_0	3	9		01	8a1;8a2;8b1;8b3;14e;		2		1	30	30	1	40.00	70.00	2	
H5970	018	0	1	04	01	H5970_018_0	5	1		11	9d;17b;	9d;	2		2			1	0.00	0.00	2	
H5970	018	0	1	04	01	H5970_018_0	5	2		01	8b2;11a;12;		2		1	20	20	2			2	
H5970	018	0	1	04	01	H5970_018_0	5	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5970	018	0	1	04	01	H5970_018_0	5	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13c;14b;14c;	2		1	50	50	2			2	
H5970	018	0	1	04	01	H5970_018_0	5	5		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5970	019	0	1	04	01	H5970_019_0	3	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H5970	019	0	1	04	01	H5970_019_0	3	2		01	6;11a;12;		2		1	20	20	2			2	
H5970	019	0	1	04	01	H5970_019_0	3	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
H5970	019	0	1	04	01	H5970_019_0	3	4		10		18a;18b;	2		1	25	25	2			2	
H5970	019	0	1	04	01	H5970_019_0	3	5		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13c;14b;14c;16a;16b;	2		1	50	50	2			2	
H5970	019	0	1	04	01	H5970_019_0	3	6		10		13b;	1	25.00	1	50	50	2			2	
H5970	019	0	1	04	01	H5970_019_0	3	7		01	14a;		2		1	50	50	1	0.00	0.00	2	
H5970	801	0	1	04	01	H5970_801_0	5	1		01	6;14a;		2		1	0	0	2			2	
H5970	801	0	1	04	01	H5970_801_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5970	802	0	1	04	01	H5970_802_0	5	1		01	6;14a;		2		1	0	0	2			2	
H5970	802	0	1	04	01	H5970_802_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5970	803	0	1	04	01	H5970_803_0	4	1		01	6;14a;		2		1	0	0	2			2	
H5970	803	0	1	04	01	H5970_803_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5970	805	0	2	04	01	H5970_805_0	4	1		01	6;14a;		2		1	0	0	2			2	
H5970	805	0	2	04	01	H5970_805_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5970	806	0	2	04	01	H5970_806_0	4	1		01	6;14a;		2		1	0	0	2			2	
H5970	806	0	2	04	01	H5970_806_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H5970	807	0	2	04	01	H5970_807_0	4	1		01	6;14a;		2		1	0	0	2			2	
H5970	807	0	2	04	01	H5970_807_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H6328	001	0	1	04	01	H6328_001_0	5	1	$20 Copay	01	3-1;3-2;3-3;7b;7c;		2		2			1	20.00	20.00	2	
H6328	001	0	1	04	01	H6328_001_0	5	10	$75 to $200 Copay	01	8b1;		2		2			1	75.00	200.00	2	
H6328	001	0	1	04	01	H6328_001_0	5	11	20% Coinsurance	01	11c;14d;14e;		2		1	20	20	2			2	
H6328	001	0	1	04	01	H6328_001_0	5	12	30% Coinsurance	01	8b2;9d;11a;11b;15;		2		1	30	30	2			2	
H6328	001	0	1	04	01	H6328_001_0	5	13	50% Coinsurance	11	17b;	17b;	2		1	50	50	2			2	
H6328	001	0	1	04	01	H6328_001_0	5	14	$45 Copay	01	7d;		2		2			1	45.00	45.00	2	
H6328	001	0	1	04	01	H6328_001_0	5	15	$200 Copay	01	9b;		2		2			1	200.00	200.00	2	
H6328	001	0	1	04	01	H6328_001_0	5	2	$30 Copay	11	7i;14a;	14c;	2		2			1	30.00	30.00	2	
H6328	001	0	1	04	01	H6328_001_0	5	3	$35 Copay	11	7a;7f;7g;16b;17a;18a;	16a;17a;18a;	2		2			1	35.00	35.00	2	
H6328	001	0	1	04	01	H6328_001_0	5	4	$40 Copay	01	6;		2		2			1	40.00	40.00	2	
H6328	001	0	1	04	01	H6328_001_0	5	5	$50 Copay	01	7e;7h;9c;12;		2		2			1	50.00	50.00	2	
H6328	001	0	1	04	01	H6328_001_0	5	6	$100 Copay	01	5;		2		2			1	100.00	100.00	2	
H6328	001	0	1	04	01	H6328_001_0	5	7	$225 Copay	01	10a;		2		2			1	225.00	225.00	2	
H6328	001	0	1	04	01	H6328_001_0	5	8	$250 Copay	01	9a;		2		2			1	250.00	250.00	2	
H6328	001	0	1	04	01	H6328_001_0	5	9	$10 to $25 Copay	01	8a1;8a2;8b3;		2		2			1	10.00	25.00	2	
H6328	002	0	1	04	01	H6328_002_0	4	1	$20 Copay	01	3-1;3-2;3-3;		2		2			1	20.00	20.00	2	
H6328	002	0	1	04	01	H6328_002_0	4	10	$75 to $200 Copay	01	8b1;		2		2			1	75.00	200.00	2	
H6328	002	0	1	04	01	H6328_002_0	4	11	20% Coinsurance	01	11c;14d;14e;		2		1	20	20	2			2	
H6328	002	0	1	04	01	H6328_002_0	4	12	30% Coinsurance	01	8b2;9d;11a;11b;15;		2		1	30	30	2			2	
H6328	002	0	1	04	01	H6328_002_0	4	13	50% Coinsurance	11	17b;	17b;	2		1	50	50	2			2	
H6328	002	0	1	04	01	H6328_002_0	4	14	$50 Copay	01	7d;		2		2			1	50.00	50.00	2	
H6328	002	0	1	04	01	H6328_002_0	4	15	$45 Copay	01	7g;7i;		2		2			1	45.00	45.00	2	
H6328	002	0	1	04	01	H6328_002_0	4	2	$30 Copay	11	7b;7c;8b3;14a;	14c;	2		2			1	30.00	30.00	2	
H6328	002	0	1	04	01	H6328_002_0	4	3	$40 Copay	11	6;7a;7f;16b;17a;18a;	17a;	2		2			1	40.00	40.00	2	
H6328	002	0	1	04	01	H6328_002_0	4	4	$55 Copay	01	7e;7h;9c;12;		2		2			1	55.00	55.00	2	
H6328	002	0	1	04	01	H6328_002_0	4	5	$225 Copay	01	10a;		2		2			1	225.00	225.00	2	
H6328	002	0	1	04	01	H6328_002_0	4	6	$125 Copay	01	5;		2		2			1	125.00	125.00	2	
H6328	002	0	1	04	01	H6328_002_0	4	7	$250 Copay	01	9b;		2		2			1	250.00	250.00	2	
H6328	002	0	1	04	01	H6328_002_0	4	8	$325 Copay	01	9a;		2		2			1	325.00	325.00	2	
H6328	002	0	1	04	01	H6328_002_0	4	9	$15 to $25 Copay	01	8a1;8a2;		2		2			1	15.00	25.00	2	
H6328	003	0	1	04	01	H6328_003_0	4	1	$300 copay	01	9b;		2		2			1	300.00	300.00	2	
H6328	003	0	1	04	01	H6328_003_0	4	10	$75 to $250	01	8b1;		2		2			1	75.00	250.00	2	
H6328	003	0	1	04	01	H6328_003_0	4	11	20% Coinsurance	01	11c;14d;14e;		2		1	20	20	2			2	
H6328	003	0	1	04	01	H6328_003_0	4	12	30% Coinsurance	01	8b2;9d;11a;11b;15;		2		1	30	30	2			2	
H6328	003	0	1	04	01	H6328_003_0	4	13	50% Coinsurance	01	6;17b;		2		1	50	50	2			2	
H6328	003	0	1	04	01	H6328_003_0	4	14	40% Coinsurance	01	12;		2		1	40	40	2			2	
H6328	003	0	1	04	01	H6328_003_0	4	2	$25 copay	01	3-1;3-2;3-3;8a1;8a2;8b3;		2		2			1	25.00	25.00	2	
H6328	003	0	1	04	01	H6328_003_0	4	3	$30 copay	11	14a;	14c;	2		2			1	30.00	30.00	2	
H6328	003	0	1	04	01	H6328_003_0	4	4	$40 copay	01	7b;		2		2			1	40.00	40.00	2	
H6328	003	0	1	04	01	H6328_003_0	4	5	$50 Copay	01	7a;7g;16b;17a;18a;		2		2			1	50.00	50.00	2	
H6328	003	0	1	04	01	H6328_003_0	4	6	$60 Copay	01	7c;7d;7e;7f;7h;7i;9c;		2		2			1	60.00	60.00	2	
H6328	003	0	1	04	01	H6328_003_0	4	7	$150 Copay	01	5;		2		2			1	150.00	150.00	2	
H6328	003	0	1	04	01	H6328_003_0	4	8	$200 Copay	01	10a;		2		2			1	200.00	200.00	2	
H6328	003	0	1	04	01	H6328_003_0	4	9	$350 Copay	01	9a;		2		2			1	350.00	350.00	2	
H6328	005	0	1	04	01	H6328_005_0	3	1	$20 Copay	01	3-1;3-2;3-3;7c;7i;		2		2			1	20.00	20.00	2	
H6328	005	0	1	04	01	H6328_005_0	3	10	$75 to $200 Copay	01	8b1;		2		2			1	75.00	200.00	2	
H6328	005	0	1	04	01	H6328_005_0	3	11	30% Coinsurance	01	8b2;9d;14d;14e;15;		2		1	30	30	2			2	
H6328	005	0	1	04	01	H6328_005_0	3	12	35% Coinsurance	01	12;		2		1	35	35	2			2	
H6328	005	0	1	04	01	H6328_005_0	3	13	50% Coinsurance	11	17b;	17b;	2		1	50	50	2			2	
H6328	005	0	1	04	01	H6328_005_0	3	14	20% Coinsurance	01	11a;11b;11c;		2		1	20	20	2			2	
H6328	005	0	1	04	01	H6328_005_0	3	15	$225 Copay	01	10a;		2		2			1	225.00	225.00	2	
H6328	005	0	1	04	01	H6328_005_0	3	2	$30 Copay	11	14a;	14c;	2		2			1	30.00	30.00	2	
H6328	005	0	1	04	01	H6328_005_0	3	3	$35 Copay	11	16b;17a;18a;	16a;17a;	2		2			1	35.00	35.00	2	
H6328	005	0	1	04	01	H6328_005_0	3	4	$40 Copay	01	6;7a;7b;7g;		2		2			1	40.00	40.00	2	
H6328	005	0	1	04	01	H6328_005_0	3	5	$50 Copay	01	7d;7e;7f;7h;9c;		2		2			1	50.00	50.00	2	
H6328	005	0	1	04	01	H6328_005_0	3	6	$100 Copay	01	5;		2		2			1	100.00	100.00	2	
H6328	005	0	1	04	01	H6328_005_0	3	7	$175 Copay	01	9b;		2		2			1	175.00	175.00	2	
H6328	005	0	1	04	01	H6328_005_0	3	8	$200 Copay	01	9a;		2		2			1	200.00	200.00	2	
H6328	005	0	1	04	01	H6328_005_0	3	9	$10 to $25 Copay	01	8a1;8a2;8b3;		2		2			1	10.00	25.00	2	
H6328	801	0	1	04	01	H6328_801_0	1	1		01	6;14a;		2		1	0	0	2			2	
H6328	801	0	1	04	01	H6328_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H6328	802	0	1	04	01	H6328_802_0	1	1		01	6;14a;		2		1	0	0	2			2	
H6328	802	0	1	04	01	H6328_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H6328	803	0	1	04	01	H6328_803_0	1	1		01	6;14a;		2		1	0	0	2			2	
H6328	803	0	1	04	01	H6328_803_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H6328	804	0	1	04	01	H6328_804_0	1	1		01	6;14a;		2		1	0	0	2			2	
H6328	804	0	1	04	01	H6328_804_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H6348	001	0	1	04	01	H6348_001_0	2	1	40% coinsurance OON services	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b3;9a;9b;9c;9d;10a;14e;16b;17a;17b;18a;	7f;9d;17a;17b;18a;18b;	2		1	40	40	2			2	
H6348	001	0	1	04	01	H6348_001_0	2	2	20% coinsurance OON services	01	8b2;11a;11b;11c;12;15;		2		1	20	20	2			2	
H6348	001	0	1	04	01	H6348_001_0	2	3	$0 cost share OON benefits	11	6;14a;14d;	14c;16a;	2		2			2			2	
H6348	001	0	1	04	01	H6348_001_0	2	4	OTC	10		13b;	1	65.00	2			2			2	
H6348	002	0	1	04	01	H6348_002_0	2	1	40% coinsurance OON services	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b3;9a;9b;9c;9d;10a;14e;16b;17a;17b;18a;	7f;9d;17a;17b;18a;18b;	2		1	40	40	2			2	
H6348	002	0	1	04	01	H6348_002_0	2	2	20% coinsurance OON services	01	8b2;11a;11b;11c;12;15;		2		1	20	20	2			2	
H6348	002	0	1	04	01	H6348_002_0	2	3	$0 cost share OON benefits	11	6;14a;14d;	14c;16a;	2		2			2			2	
H6348	002	0	1	04	01	H6348_002_0	2	4	OTC	10		13b;	1	65.00	2			2			2	
H6348	003	0	1	04	01	H6348_003_0	2	1	40% coinsurance OON services	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b3;9a;9b;9c;9d;10a;14e;16b;17a;17b;18a;	7f;9d;17a;17b;18a;18b;	2		1	40	40	2			2	
H6348	003	0	1	04	01	H6348_003_0	2	2	20% coinsurance OON services	01	8b2;11a;11b;11c;12;15;		2		1	20	20	2			2	
H6348	003	0	1	04	01	H6348_003_0	2	3	$0 cost share OON benefits	11	6;14a;14d;	14c;16a;	2		2			2			2	
H6348	003	0	1	04	01	H6348_003_0	2	4	OTC	10		13b;	1	65.00	2			2			2	
H6502	001	0	1	04	01	H6502_001_0	7	1	Services with 20% coins	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;14c;	2		1	20	20	2			2	
H6502	001	0	1	04	01	H6502_001_0	7	2	Ambulance	01	10a;		2		2			1	290.00	290.00	2	
H6502	001	0	1	04	01	H6502_001_0	7	3	Hearing Aids	10		18b;	2		2			1	399.00	699.00	2	
H6502	001	0	1	04	01	H6502_001_0	7	4	Hearing Exams	10		18a;	2		2			1	40.00	40.00	2	
H6502	001	0	1	04	01	H6502_001_0	7	5	Eyewear and Routine Eye Exams	10		17a;17b;	2		1	50	50	2			2	
H6502	001	0	1	04	01	H6502_001_0	7	6	Preventive Dental	10		16a;	2		2			1	40.00	40.00	2	
H6502	801	0	1	04	01	H6502_801_0	3	1		01	6;14a;		2		1	0	0	2			2	
H6502	801	0	1	04	01	H6502_801_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H6502	802	0	1	04	01	H6502_802_0	3	1		01	6;14a;		2		1	0	0	2			2	
H6502	802	0	1	04	01	H6502_802_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H6502	803	0	1	04	01	H6502_803_0	3	1		01	6;14a;		2		1	0	0	2			2	
H6502	803	0	1	04	01	H6502_803_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H6528	006	0	1	04	01	H6528_006_0	3	1	Group 1	11	7c;7d;7f;7i;	7f;	2		2			1	40.00	40.00	2	
H6528	006	0	1	04	01	H6528_006_0	3	10	Group 10	01	8b3;		2		2			1	14.00	14.00	2	
H6528	006	0	1	04	01	H6528_006_0	3	11	Group 11	11	9d;14a;14d;14e;17a;17b;	9d;14b;14c;16a;16b;17a;17b;	2		2			1	0.00	0.00	2	
H6528	006	0	1	04	01	H6528_006_0	3	12	Group 12	01	10a;		2		2			1	250.00	250.00	2	
H6528	006	0	1	04	01	H6528_006_0	3	13	Group 13	10		18b;	2		2			1	330.00	380.00	2	
H6528	006	0	1	04	01	H6528_006_0	3	14	Group 14	01	7g;		2		2			1	10.00	40.00	2	
H6528	006	0	1	04	01	H6528_006_0	3	15	Group 15	01	8a2;		2		2			1	5.00	5.00	2	
H6528	006	0	1	04	01	H6528_006_0	3	2	Group 2	01	5;		2		2			1	55.00	55.00	2	
H6528	006	0	1	04	01	H6528_006_0	3	3	Group 3	01	6;		2		1	50	50	2			2	
H6528	006	0	1	04	01	H6528_006_0	3	4	Group 4	11	7a;18a;	18a;	2		2			1	10.00	10.00	2	
H6528	006	0	1	04	01	H6528_006_0	3	5	Group 5	01	11a;		2		1	45	45	2			2	
H6528	006	0	1	04	01	H6528_006_0	3	6	Group 6	01	7e;7h;9c;		2		2			1	30.00	40.00	2	
H6528	006	0	1	04	01	H6528_006_0	3	7	Group 7	01	9a;9b;		2		2			1	325.00	325.00	2	
H6528	006	0	1	04	01	H6528_006_0	3	8	Group 8	01	8a1;8b1;8b2;11b;11c;12;15;16b;		2		1	20	20	2			2	
H6528	006	0	1	04	01	H6528_006_0	3	9	Group 9	01	3-1;3-2;3-3;7b;		2		2			1	20.00	20.00	2	
H6622	001	0	1	01	01	H6622_001_0	3	1														
H6622	002	0	1	01	01	H6622_002_0	2	1														
H6622	004	0	1	01	01	H6622_004_0	2	1														
H6622	005	0	1	01	01	H6622_005_0	2	1														
H6622	007	0	1	01	01	H6622_007_0	2	1														
H6622	008	0	1	01	01	H6622_008_0	3	1														
H6622	010	0	1	01	01	H6622_010_0	2	1														
H6622	011	0	1	01	01	H6622_011_0	3	1														
H6622	012	0	1	01	01	H6622_012_0	3	1														
H6622	013	0	1	01	01	H6622_013_0	2	1														
H6622	014	0	1	01	01	H6622_014_0	3	1														
H6622	015	0	1	01	01	H6622_015_0	3	1														
H6622	016	0	1	01	01	H6622_016_0	3	1														
H6622	017	0	1	01	01	H6622_017_0	4	1														
H6622	018	0	1	01	01	H6622_018_0	2	1														
H6622	019	0	1	01	01	H6622_019_0	3	1														
H6622	020	0	1	01	01	H6622_020_0	3	1														
H6622	021	1	1	01	01	H6622_021_1	3	1														
H6622	021	2	1	01	01	H6622_021_2	3	1														
H6622	022	0	1	01	01	H6622_022_0	2	1														
H6622	023	0	1	01	01	H6622_023_0	2	1														
H6622	024	0	1	01	01	H6622_024_0	3	1														
H6622	025	0	1	01	01	H6622_025_0	2	1														
H6622	026	0	1	01	01	H6622_026_0	2	1														
H6622	027	0	1	01	01	H6622_027_0	3	1														
H6622	028	0	1	01	01	H6622_028_0	2	1														
H6622	029	0	1	01	01	H6622_029_0	3	1														
H6622	030	0	1	01	01	H6622_030_0	3	1														
H6622	031	0	1	01	01	H6622_031_0	4	1														
H6622	032	0	1	01	01	H6622_032_0	2	1														
H6622	033	0	1	01	01	H6622_033_0	2	1														
H6622	034	0	1	01	01	H6622_034_0	2	1														
H6622	035	0	1	01	01	H6622_035_0	2	1														
H6622	036	0	1	01	01	H6622_036_0	2	1														
H6622	037	0	1	01	01	H6622_037_0	2	1														
H6622	038	0	1	01	01	H6622_038_0	4	1														
H6622	039	0	1	01	01	H6622_039_0	2	1														
H6622	040	0	1	01	01	H6622_040_0	2	1														
H6622	041	0	1	01	01	H6622_041_0	2	1														
H6622	042	0	1	01	01	H6622_042_0	2	1														
H6622	043	0	1	01	01	H6622_043_0	2	1														
H6622	044	0	1	01	01	H6622_044_0	2	1														
H6622	045	0	1	01	01	H6622_045_0	2	1														
H6622	046	0	1	01	01	H6622_046_0	2	1														
H6622	047	0	1	01	01	H6622_047_0	2	1														
H6622	048	0	1	01	01	H6622_048_0	3	1														
H6622	049	0	1	01	01	H6622_049_0	2	1														
H6743	001	0	1	04	01	H6743_001_0	10	1	Primary Care Physician Services	01	7a;		2		2			1	40.00	40.00	2	
H6743	001	0	1	04	01	H6743_001_0	10	10	Health Education	10		14c;	2		2			2			2	
H6743	001	0	1	04	01	H6743_001_0	10	11	ASC	01	9b;		2		2			1	325.00	325.00	2	
H6743	001	0	1	04	01	H6743_001_0	10	12	OP Hospital	01	9a;		2		1	40	40	2			2	
H6743	001	0	1	04	01	H6743_001_0	10	2	Specialist Services	01	7d;16b;17a;18a;		2		2			1	50.00	50.00	2	
H6743	001	0	1	04	01	H6743_001_0	10	3	Outpatient Services	01	3-1;3-2;3-3;5;7c;7e;7f;7g;7h;7i;8b1;8b2;8b3;9c;11a;11b;12;15;		2		1	30	30	2			2	
H6743	001	0	1	04	01	H6743_001_0	10	4	Chiropractic Services	01	7b;		2		1	50	50	2			2	
H6743	001	0	1	04	01	H6743_001_0	10	5	Ambulance	01	10a;		2		1	20	20	2			2	
H6743	001	0	1	04	01	H6743_001_0	10	6	Diagnostic Tests	01	8a1;		2		1	30	30	2			2	
H6743	001	0	1	04	01	H6743_001_0	10	7	Preventive Services	11	9d;11c;14a;14d;14e;17b;	9d;14b;	2		2			2			2	
H6743	001	0	1	04	01	H6743_001_0	10	8	Home Health	01	6;		2		1	15	15	2			2	
H6743	001	0	1	04	01	H6743_001_0	10	9	Laboratory Services	01	8a2;		2		1	25	25	2			2	
H6743	002	0	1	04	01	H6743_002_0	6	1	Preventive Services	11	8a2;9d;11c;14a;14d;14e;17b;	9d;14b;	2		2			2			2	
H6743	002	0	1	04	01	H6743_002_0	6	10	Health Club Membership	10		14c;	1	500.00	2			2			2	
H6743	002	0	1	04	01	H6743_002_0	6	11	Supplemental Eyewear	10		17b;	2		2			2			2	
H6743	002	0	1	04	01	H6743_002_0	6	2	Primary Care Physician Services	01	7a;		2		2			1	30.00	30.00	2	
H6743	002	0	1	04	01	H6743_002_0	6	3	Specialist Services	11	3-1;3-2;3-3;5;7c;7d;7e;7f;7g;7h;7i;9c;16b;17a;18a;	17a;	2		2			1	40.00	40.00	2	
H6743	002	0	1	04	01	H6743_002_0	6	4	ASC Services	01	9b;		2		2			1	325.00	325.00	2	
H6743	002	0	1	04	01	H6743_002_0	6	5	Ambulance	01	10a;		2		2			1	150.00	150.00	2	
H6743	002	0	1	04	01	H6743_002_0	6	6	Chiropractic Services	01	7b;		2		1	50	50	2			2	
H6743	002	0	1	04	01	H6743_002_0	6	7	Rad, Out pt hos, DME, ESRD and Part B Rx	01	8b1;8b2;8b3;9a;11a;11b;12;15;		2		1	30	30	2			2	
H6743	002	0	1	04	01	H6743_002_0	6	8	Home Health Services	01	6;		2		1	15	15	2			2	
H6743	002	0	1	04	01	H6743_002_0	6	9	Diagnostic Tests	01	8a1;		2		1	30	30	2			2	
H6743	003	0	1	04	01	H6743_003_0	10	1	Preventive Services	11	8a2;9d;11c;14a;14d;14e;17b;	9d;14b;17b;	2		2			2			2	
H6743	003	0	1	04	01	H6743_003_0	10	10	Health Club Membership	10		14c;	1	500.00	2			2			2	
H6743	003	0	1	04	01	H6743_003_0	10	2	Primary Care Physician Services	01	7a;		2		2			1	30.00	30.00	2	
H6743	003	0	1	04	01	H6743_003_0	10	3	Specialist Services	11	3-1;3-2;3-3;5;7c;7d;7e;7f;7g;7h;7i;9c;16b;17a;18a;	17a;	2		2			1	40.00	40.00	2	
H6743	003	0	1	04	01	H6743_003_0	10	4	ASC Services	01	9b;		2		2			1	325.00	325.00	2	
H6743	003	0	1	04	01	H6743_003_0	10	5	Ambulance	01	10a;		2		2			1	200.00	200.00	2	
H6743	003	0	1	04	01	H6743_003_0	10	6	Chiropractic Services	01	7b;		2		1	50	50	2			2	
H6743	003	0	1	04	01	H6743_003_0	10	7	Rad, Out pt hos, DME, ESRD and Part B Rx	01	8b1;8b2;8b3;9a;11a;11b;12;15;		2		1	30	30	2			2	
H6743	003	0	1	04	01	H6743_003_0	10	8	Home Health Services	01	6;		2		1	15	15	2			2	
H6743	003	0	1	04	01	H6743_003_0	10	9	Diagnostic Tests	01	8a1;		2		1	30	30	2			2	
H6743	004	0	1	04	01	H6743_004_0	10	1	Primary Care Physician Services	01	7a;		2		2			1	25.00	25.00	2	
H6743	004	0	1	04	01	H6743_004_0	10	10	Health Club Membership	10		14c;	1	500.00	2			2			2	
H6743	004	0	1	04	01	H6743_004_0	10	11	Supplemental Eyewear	10		17b;	2		2			2			2	
H6743	004	0	1	04	01	H6743_004_0	10	12	Preventive Dental	10		16a;	2		2			1	15.00	15.00	2	
H6743	004	0	1	04	01	H6743_004_0	10	13	Supplemental Chiropractic Services	10		7b;	1	500.00	2			1	15.00	15.00	2	
H6743	004	0	1	04	01	H6743_004_0	10	14	Routine Podiatry	10		7f;	1	500.00	2			1	25.00	25.00	2	
H6743	004	0	1	04	01	H6743_004_0	10	15	Routine Hearing	10		18a;	2		2			1	25.00	25.00	2	
H6743	004	0	1	04	01	H6743_004_0	10	2	Preventive Services	11	8a2;9d;11c;14a;14d;14e;17b;	9d;14b;18b;	2		2			2			2	
H6743	004	0	1	04	01	H6743_004_0	10	3	Specialist services	11	3-1;3-2;3-3;5;7c;7d;7e;7f;7g;7h;7i;9c;16b;17a;18a;	17a;	2		2			1	30.00	30.00	2	
H6743	004	0	1	04	01	H6743_004_0	10	4	Outpatient Services/ASC	01	9a;9b;		2		2			1	325.00	325.00	2	
H6743	004	0	1	04	01	H6743_004_0	10	5	Ambulance	01	10a;		2		2			1	150.00	150.00	2	
H6743	004	0	1	04	01	H6743_004_0	10	6	Medicare Covered Chiropractic Services	01	7b;		2		2			1	15.00	15.00	2	
H6743	004	0	1	04	01	H6743_004_0	10	7	Radiolgy, DME, and Part B Rx	01	8a1;8b1;8b2;8b3;11a;11b;15;		2		1	20	20	2			2	
H6743	004	0	1	04	01	H6743_004_0	10	8	Home Health Services	01	6;		2		1	15	15	2			2	
H6743	004	0	1	04	01	H6743_004_0	10	9	ESRD	01	12;		2		1	30	30	2			2	
H6743	006	0	1	04	01	H6743_006_0	6	1	Primary Care Physician Services	01	7a;		2		2			1	40.00	40.00	2	
H6743	006	0	1	04	01	H6743_006_0	6	10	Health Education	10		14c;	2		2			2			2	
H6743	006	0	1	04	01	H6743_006_0	6	2	Specialist Services	01	7d;16b;17a;18a;		2		2			1	50.00	50.00	2	
H6743	006	0	1	04	01	H6743_006_0	6	3	Outpatient Services	01	3-1;3-2;3-3;5;7c;7e;7f;7g;7h;7i;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;15;		2		1	30	30	2			2	
H6743	006	0	1	04	01	H6743_006_0	6	4	Chiropractic Services	01	7b;		2		1	50	50	2			2	
H6743	006	0	1	04	01	H6743_006_0	6	5	Ambulance	01	10a;		2		1	20	20	2			2	
H6743	006	0	1	04	01	H6743_006_0	6	6	Diagnostic Tests	01	8a1;		2		1	30	30	2			2	
H6743	006	0	1	04	01	H6743_006_0	6	7	Preventive Services	11	9d;11c;14a;14d;14e;17b;	9d;14b;	2		2			2			2	
H6743	006	0	1	04	01	H6743_006_0	6	8	Home Health Services	01	6;		2		1	15	15	2			2	
H6743	006	0	1	04	01	H6743_006_0	6	9	Laboratory Services	01	8a2;		2		1	25	25	2			2	
H6743	007	0	1	04	01	H6743_007_0	10	1	Primary Care Physician Services	01	7a;		2		2			1	40.00	40.00	2	
H6743	007	0	1	04	01	H6743_007_0	10	10	Outpatient Hospital Services	01	9a;		2		1	40	40	2			2	
H6743	007	0	1	04	01	H6743_007_0	10	11	Health Education	10		14c;	2		2			2			2	
H6743	007	0	1	04	01	H6743_007_0	10	12	ASC Services	01	9b;		2		2			1	325.00	325.00	2	
H6743	007	0	1	04	01	H6743_007_0	10	2	Specialist Services	01	7d;16b;17a;18a;		2		2			1	50.00	50.00	2	
H6743	007	0	1	04	01	H6743_007_0	10	3	Outpatient Services	01	3-1;3-2;3-3;5;7c;7e;7f;7g;7h;7i;8b1;8b2;8b3;9c;11a;11b;12;15;		2		1	30	30	2			2	
H6743	007	0	1	04	01	H6743_007_0	10	4	Chiropractic Services	01	7b;		2		1	50	50	2			2	
H6743	007	0	1	04	01	H6743_007_0	10	5	Ambulance	01	10a;		2		1	20	20	2			2	
H6743	007	0	1	04	01	H6743_007_0	10	6	Diagnostic Tests	01	8a1;		2		1	30	30	2			2	
H6743	007	0	1	04	01	H6743_007_0	10	7	Preventive Services	11	9d;11c;14a;14d;14e;17b;	9d;14b;	2		2			2			2	
H6743	007	0	1	04	01	H6743_007_0	10	8	Home Health Services	01	6;		2		1	15	15	2			2	
H6743	007	0	1	04	01	H6743_007_0	10	9	Laboratory Services	01	8a2;		2		1	25	25	2			2	
H6743	014	0	1	04	01	H6743_014_0	10	1	Primary Care Physician Services	01	7a;		2		2			1	40.00	40.00	2	
H6743	014	0	1	04	01	H6743_014_0	10	10	Health Education	10		14c;	2		2			2			2	
H6743	014	0	1	04	01	H6743_014_0	10	11	ASC Services	01	9b;		2		2			1	325.00	325.00	2	
H6743	014	0	1	04	01	H6743_014_0	10	2	Specialist Services	01	7d;16b;17a;18a;		2		2			1	50.00	50.00	2	
H6743	014	0	1	04	01	H6743_014_0	10	3	Outpatient Services	01	3-1;3-2;3-3;5;7c;7e;7f;7g;7h;7i;8b1;8b2;8b3;9a;9c;11a;11b;12;15;		2		1	30	30	2			2	
H6743	014	0	1	04	01	H6743_014_0	10	4	Chiropractic Services	01	7b;		2		1	50	50	2			2	
H6743	014	0	1	04	01	H6743_014_0	10	5	Ambulance	01	10a;		2		1	20	20	2			2	
H6743	014	0	1	04	01	H6743_014_0	10	6	Diagnostic Tests	01	8a1;		2		1	30	30	2			2	
H6743	014	0	1	04	01	H6743_014_0	10	7	Preventive Services	11	9d;11c;14a;14d;14e;17b;	9d;14b;	2		2			2			2	
H6743	014	0	1	04	01	H6743_014_0	10	8	Home Health	01	6;		2		1	15	15	2			2	
H6743	014	0	1	04	01	H6743_014_0	10	9	Laboratory Services	01	8a2;		2		1	25	25	2			2	
H6743	016	0	1	04	01	H6743_016_0	10	1	Preventive Services	11	8a2;9d;11c;14a;14d;14e;17b;	9d;14b;	2		2			2			2	
H6743	016	0	1	04	01	H6743_016_0	10	2	Primary Care Physician Services	01	7a;		2		2			1	30.00	30.00	2	
H6743	016	0	1	04	01	H6743_016_0	10	3	Specialist Services	11	3-1;3-2;3-3;5;7c;7d;7e;7f;7g;7h;7i;9c;16b;17a;18a;	17a;	2		2			1	40.00	40.00	2	
H6743	016	0	1	04	01	H6743_016_0	10	4	ASC	01	9b;		2		2			1	325.00	325.00	2	
H6743	016	0	1	04	01	H6743_016_0	10	5	Ambulance	01	10a;		2		2			1	200.00	200.00	2	
H6743	016	0	1	04	01	H6743_016_0	10	6	Chiropractic Services	01	7b;		2		1	50	50	2			2	
H6743	016	0	1	04	01	H6743_016_0	10	7	Rad, OP hosp, DME, ESRD and Part B Rx	01	8a1;8b1;8b2;8b3;9a;11a;11b;12;15;		2		1	30	30	2			2	
H6743	016	0	1	04	01	H6743_016_0	10	8	Home Health Services	01	6;		2		1	15	15	2			2	
H6743	016	0	1	04	01	H6743_016_0	10	9	Health Club Membership	10		14c;	1	500.00	2			2			2	
H6786	002	0	1	04	01	H6786_002_0	5	1	$0 copay	11	9d;16b;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H6786	002	0	1	04	01	H6786_002_0	5	2	$65 copay	01	7b;7c;7d;7e;7f;7h;7i;		2		2			1	65.00	65.00	2	
H6786	002	0	1	04	01	H6786_002_0	5	3	$55 copay	01	7a;7g;		2		2			1	55.00	55.00	2	
H6786	002	0	1	04	01	H6786_002_0	5	4	40% coinsurance	11	3-1;3-2;3-3;5;6;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14a;14d;14e;17a;18a;	14b;	2		1	40	40	2			2	
H6786	002	0	1	04	01	H6786_002_0	5	5	20% coinsurance	11	12;	16a;	2		1	20	20	2			2	
H6786	002	0	1	04	01	H6786_002_0	5	6	Ambulance	01	10a;		2		1	20	20	1	210.00	210.00	2	
H6786	002	0	1	04	01	H6786_002_0	5	7	30% Coinsurance	01	15;		2		1	30	30	2			2	
H6786	002	0	1	04	01	H6786_002_0	5	8	$0 Copay	10		14c;	1	95.00	2			1	0.00	0.00	2	
H6786	801	0	1	04	01	H6786_801_0	1	1		01	6;14a;		2		1	0	0	2			2	
H6786	801	0	1	04	01	H6786_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H6786	802	0	1	04	01	H6786_802_0	1	1		01	6;14a;		2		1	0	0	2			2	
H6786	802	0	1	04	01	H6786_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H6786	803	0	1	04	01	H6786_803_0	1	1		01	6;14a;		2		1	0	0	2			2	
H6786	803	0	1	04	01	H6786_803_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H7006	001	0	1	04	01	H7006_001_0	10	1	Preventive Services	11	8a1;8a2;9d;11c;14a;14d;14e;17b;	9d;14b;	2		2			2			2	
H7006	001	0	1	04	01	H7006_001_0	10	10	Supplemental Eyewear	10		17b;	2		2			2			2	
H7006	001	0	1	04	01	H7006_001_0	10	11	ESRD	01	12;		2		1	30	30	2			2	
H7006	001	0	1	04	01	H7006_001_0	10	12	Outpt Hosp	01	9a;		2		2			1	325.00	325.00	2	
H7006	001	0	1	04	01	H7006_001_0	10	2	Office Visits, Home Health	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;9c;16b;17a;18a;	17a;	2		2			1	30.00	30.00	2	
H7006	001	0	1	04	01	H7006_001_0	10	3	ASC Services	01	9b;		2		2			1	225.00	225.00	2	
H7006	001	0	1	04	01	H7006_001_0	10	4	Ambulance	01	10a;		2		2			1	175.00	175.00	2	
H7006	001	0	1	04	01	H7006_001_0	10	5	DME, Part B Drugs	01	11a;11b;15;		2		1	20	20	2			2	
H7006	001	0	1	04	01	H7006_001_0	10	6	Radiology	01	8b1;8b2;8b3;		2		1	20	20	2			2	
H7006	001	0	1	04	01	H7006_001_0	10	7	Health Club Membership	10		14c;	1	500.00	2			2			2	
H7006	001	0	1	04	01	H7006_001_0	10	8	Routine Podiatry	10		7f;	1	500.00	2			1	25.00	25.00	2	
H7006	001	0	1	04	01	H7006_001_0	10	9	Preventive Dental	10		16a;	2		2			2			2	
H7006	003	0	1	04	01	H7006_003_0	10	1	Preventive Services	11	8a1;8a2;9d;11c;14a;14d;14e;17b;	9d;14b;	2		2			2			2	
H7006	003	0	1	04	01	H7006_003_0	10	10	Outpt Hosp	01	9a;		2		2			1	325.00	325.00	2	
H7006	003	0	1	04	01	H7006_003_0	10	2	Office Visits	01	3-1;3-2;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;9c;16b;17a;18a;		2		2			1	35.00	35.00	2	
H7006	003	0	1	04	01	H7006_003_0	10	3	ASC Services	01	9b;		2		2			1	225.00	225.00	2	
H7006	003	0	1	04	01	H7006_003_0	10	4	Ambulance	01	10a;		2		2			1	175.00	175.00	2	
H7006	003	0	1	04	01	H7006_003_0	10	5	DME	01	11a;11b;		2		1	30	30	2			2	
H7006	003	0	1	04	01	H7006_003_0	10	6	Radiology and ESRD	01	8b1;8b2;12;		2		1	30	30	2			2	
H7006	003	0	1	04	01	H7006_003_0	10	7	Part B Drugs and Outpatient X-Rays	01	6;8b3;15;		2		1	20	20	2			2	
H7006	003	0	1	04	01	H7006_003_0	10	8	Health Club Membership	10		14c;	1	500.00	2			2			2	
H7006	003	0	1	04	01	H7006_003_0	10	9	Pulmonary Rehabilitation Services	01	3-3;		2		2			1	30.00	30.00	2	
H7301	002	0	1	04	01	H7301_002_0	6	1	OON Standard Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;12;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		1	40	40	2			2	
H7301	002	0	1	04	01	H7301_002_0	6	2	OON Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H7301	002	0	1	04	01	H7301_002_0	6	3	OON Supplemental Benefits 14c	10		14c;	2		1	0	40	2			2	
H7301	002	0	1	04	01	H7301_002_0	6	4	0 cost share	11	14d;	16a;16b;17b;	2		1	0	0	2			2	
H7301	002	0	1	04	01	H7301_002_0	6	5	OON 14a Preventive Benefits	01	14a;		2		1	0	40	2			2	
H7301	002	0	1	04	01	H7301_002_0	6	6	OTC $25 Monthly	10		13b;	1	25.00	2			1	0.00	0.00	2	
H7301	002	0	1	04	01	H7301_002_0	6	7	35% Cost Share	01	11a;11b;		2		1	35	35	2			2	
H7301	002	0	1	04	01	H7301_002_0	6	8	0% - 20%	01	11c;		2		1	0	20	2			2	
H7301	006	0	1	04	01	H7301_006_0	3	1	50% Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;14e;15;16b;17a;17b;18a;	9d;14b;	2		1	50	50	2			2	
H7301	006	0	1	04	01	H7301_006_0	3	2	Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H7301	006	0	1	04	01	H7301_006_0	3	3	20% Tier	01	12;		2		1	20	20	2			2	
H7301	006	0	1	04	01	H7301_006_0	3	4	0%-50% Tier	11	14a;	14c;	2		1	0	50	2			2	
H7301	006	0	1	04	01	H7301_006_0	3	5	0% Tier	11	14d;	16a;17a;17b;18a;	2		1	0	0	2			2	
H7301	006	0	1	04	01	H7301_006_0	3	6	OTC $25 Monthly	10		13b;	1	25.00	2			1	0.00	0.00	2	
H7301	006	0	1	04	01	H7301_006_0	3	7	35% Cost Share	01	11a;11b;		2		1	35	35	2			2	
H7301	006	0	1	04	01	H7301_006_0	3	8	0% - 20%	01	11c;		2		1	0	20	2			2	
H7301	007	0	1	04	01	H7301_007_0	4	1	OON Standard Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;17b;18a;	2		1	35	35	2			2	
H7301	007	0	1	04	01	H7301_007_0	4	2	OON Ambulance	01	10a;		2		2			1	300.00	300.00	2	
H7301	007	0	1	04	01	H7301_007_0	4	3	OON Supplemental Benefits 14c	10		14c;	2		1	0	35	2			2	
H7301	007	0	1	04	01	H7301_007_0	4	4	OON 14a Preventive Benefits	01	14a;		2		1	0	35	2			2	
H7301	007	0	1	04	01	H7301_007_0	4	5	Prev Dental	10		16a;	2		2			1	0.00	0.00	2	
H7301	007	0	1	04	01	H7301_007_0	4	6	14D Kidney Disease Education	01	14d;		2		1	0	0	2			2	
H7301	007	0	1	04	01	H7301_007_0	4	7	11c Diabetic Supplies	01	11c;		2		1	0	20	2			2	
H7301	801	0	1	04	01	H7301_801_0	1	1		01	6;14a;		2		1	0	0	2			2	
H7301	801	0	1	04	01	H7301_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H7301	803	0	1	04	01	H7301_803_0	1	1		01	6;14a;		2		1	0	0	2			2	
H7301	803	0	1	04	01	H7301_803_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H7326	001	0	1	04	01	H7326_001_0	3	1	$50	01	3-1;3-2;7a;7c;7d;7e;7f;7g;7h;7i;9c;16b;		2		2			1	50.00	50.00	2	
H7326	001	0	1	04	01	H7326_001_0	3	10	Hearing	11	18a;	18a;18b;	2		1	50	50	1	50.00	50.00	2	
H7326	001	0	1	04	01	H7326_001_0	3	2	$40	01	3-3;		2		2			1	40.00	40.00	2	
H7326	001	0	1	04	01	H7326_001_0	3	3	20%	01	5;6;7b;9d;11b;11c;12;15;		2		1	20	20	2			2	
H7326	001	0	1	04	01	H7326_001_0	3	4	30%	01	8a1;8a2;8b1;8b2;8b3;9a;9b;11a;14d;		2		1	30	30	2			2	
H7326	001	0	1	04	01	H7326_001_0	3	5	$250	01	10a;		2		2			1	250.00	250.00	2	
H7326	001	0	1	04	01	H7326_001_0	3	6	OTC	10		13b;	1	50.00	2			1	0.00	0.00	2	
H7326	001	0	1	04	01	H7326_001_0	3	7	$0	11	14a;14e;	14b;14c;	2		2			1	0.00	0.00	2	
H7326	001	0	1	04	01	H7326_001_0	3	8	Dental	10		16a;16b;	2		1	20	70	2			1	100.00
H7326	001	0	1	04	01	H7326_001_0	3	9	Vision	11	17a;17b;	17a;17b;	2		1	50	50	1	0.00	50.00	2	
H7326	002	0	1	04	01	H7326_002_0	3	1	$5-$55	01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7h;7i;8a2;8b3;9c;16b;		2		2			1	5.00	55.00	2	
H7326	002	0	1	04	01	H7326_002_0	3	10	Hearing	11	18a;	18a;18b;	2		1	50	50	1	35.00	35.00	2	
H7326	002	0	1	04	01	H7326_002_0	3	2	20%-50%	01	6;8b2;11a;11b;11c;12;14d;15;		2		1	20	50	2			2	
H7326	002	0	1	04	01	H7326_002_0	3	3	Other Healthcare Prof	01	7g;		2		2			1	5.00	35.00	2	
H7326	002	0	1	04	01	H7326_002_0	3	4	Diagnostic Proc/Tests	01	8a1;		2		2			1	0.00	100.00	2	
H7326	002	0	1	04	01	H7326_002_0	3	5	$175-$450	01	8b1;9a;9b;10a;		2		2			1	175.00	450.00	2	
H7326	002	0	1	04	01	H7326_002_0	3	6	$0	11	9d;14a;14e;	14b;14c;	2		2			1	0.00	0.00	2	
H7326	002	0	1	04	01	H7326_002_0	3	7	OTC	10		13b;	1	50.00	2			1	0.00	0.00	2	
H7326	002	0	1	04	01	H7326_002_0	3	8	Dental	10		16a;16b;	2		1	20	70	2			1	100.00
H7326	002	0	1	04	01	H7326_002_0	3	9	Vision	11	17a;17b;	17a;17b;	2		1	50	50	1	0.00	35.00	2	
H7522	001	0	1	04	01	H7522_001_0	14	1	20% coinsurance Group	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;10a;11a;11b;11c;12;14a;15;16b;17a;17b;18a;	7b;7f;9d;16a;17a;18a;	2		1	20	20	2			2	
H7522	001	0	1	04	01	H7522_001_0	14	2	50% coinsurance Group	01	5;7e;7h;9c;		2		1	50	50	2			2	
H7522	001	0	1	04	01	H7522_001_0	14	3	50% Coinsurance With Max	10		16b;17b;	2		1	50	50	2			2	
H7522	001	0	1	04	01	H7522_001_0	14	4	$O coinsurance Group with limits	10		18b;	2		2			2			2	
H7522	001	0	1	04	01	H7522_001_0	14	5	0% Coinsurance Group	11	14d;14e;	14c;	2		2			2			2	
H7522	001	0	1	04	01	H7522_001_0	14	6	Acupunture	10		13a;	1	500.00	1	50	50	2			2	
H7522	001	0	1	04	01	H7522_001_0	14	7	OTC	10		13b;	1	25.00	1	50	50	2			2	
H7522	801	0	1	04	01	H7522_801_0	9	1		01	6;14a;		2		1	0	0	2			2	
H7522	801	0	1	04	01	H7522_801_0	9	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H7522	802	0	1	04	01	H7522_802_0	9	1		01	6;14a;		2		1	0	0	2			2	
H7522	802	0	1	04	01	H7522_802_0	9	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H7728	002	0	1	04	01	H7728_002_0	7	1	$0	11	9d;16b;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H7728	002	0	1	04	01	H7728_002_0	7	2	$65 copayment	01	7b;7c;7d;7e;7f;7h;7i;		2		2			1	65.00	65.00	2	
H7728	002	0	1	04	01	H7728_002_0	7	3	40% coinsurance	11	3-1;3-2;3-3;5;6;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;	14b;	2		1	40	40	2			2	
H7728	002	0	1	04	01	H7728_002_0	7	4	$50 copayment	01	7a;7g;		2		2			1	50.00	50.00	2	
H7728	002	0	1	04	01	H7728_002_0	7	5	20% Coinsurance	11	12;	16a;	2		1	20	20	2			2	
H7728	002	0	1	04	01	H7728_002_0	7	6	Ambulance	01	10a;		2		1	20	20	1	250.00	250.00	2	
H7728	002	0	1	04	01	H7728_002_0	7	7	$95	10		14c;	1	95.00	2			1	0.00	0.00	2	
H7728	004	1	1	04	01	H7728_004_1	5	1	$0	11	9d;16b;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H7728	004	1	1	04	01	H7728_004_1	5	2	20%	11	8b2;12;15;	16a;18a;	2		1	20	20	2			2	
H7728	004	1	1	04	01	H7728_004_1	5	3	Ambulance	01	10a;		2		1	20	20	1	295.00	295.00	2	
H7728	004	1	1	04	01	H7728_004_1	5	4	Diag/Rad	01	8a1;8a2;8b1;8b3;		2		1	40	40	2			2	
H7728	004	1	1	04	01	H7728_004_1	5	5	PCP	01	7a;7g;		2		2			1	40.00	40.00	2	
H7728	004	1	1	04	01	H7728_004_1	5	6	SPEC	11	7b;7c;7d;7e;7f;7h;7i;	7f;14b;	2		2			1	60.00	60.00	2	
H7728	004	1	1	04	01	H7728_004_1	5	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;17a;18a;		2		1	40	40	2			2	
H7728	004	1	1	04	01	H7728_004_1	5	8	Eligible Supplemental Benefits	10		14c;	1	95.00	2			1	0.00	0.00	2	
H7728	004	1	1	04	01	H7728_004_1	5	9	50%	10		18b;	2		1	50	50	2			2	
H7728	004	2	1	04	01	H7728_004_2	5	1	$0	11	9d;16b;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H7728	004	2	1	04	01	H7728_004_2	5	2	20%	11	8b2;12;15;	16a;18a;	2		1	20	20	2			2	
H7728	004	2	1	04	01	H7728_004_2	5	3	Ambulance	01	10a;		2		1	20	20	1	295.00	295.00	2	
H7728	004	2	1	04	01	H7728_004_2	5	4	Diag/Rad	01	8a1;8a2;8b1;8b3;		2		1	35	35	2			2	
H7728	004	2	1	04	01	H7728_004_2	5	5	PCP	01	7a;7g;		2		2			1	40.00	40.00	2	
H7728	004	2	1	04	01	H7728_004_2	5	6	SPEC	11	7b;7c;7d;7e;7f;7h;7i;	7f;14b;	2		2			1	60.00	60.00	2	
H7728	004	2	1	04	01	H7728_004_2	5	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;17a;18a;		2		1	40	40	2			2	
H7728	004	2	1	04	01	H7728_004_2	5	8	Eligible Supplemental Benefits	10		14c;	1	95.00	2			1	0.00	0.00	2	
H7728	004	2	1	04	01	H7728_004_2	5	9	50%	10		18b;	2		1	50	50	2			2	
H7728	005	0	1	04	01	H7728_005_0	5	1	$0	11	9d;16b;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H7728	005	0	1	04	01	H7728_005_0	5	10	30% Coinsurance	01	15;		2		1	30	30	2			2	
H7728	005	0	1	04	01	H7728_005_0	5	11	50%	10		18b;	2		1	50	50	2			2	
H7728	005	0	1	04	01	H7728_005_0	5	2	20%	11	8b2;12;	16a;18a;	2		1	20	20	2			2	
H7728	005	0	1	04	01	H7728_005_0	5	3	Ambulance	01	10a;		2		1	20	20	1	295.00	295.00	2	
H7728	005	0	1	04	01	H7728_005_0	5	4	Diag/Rad	01	8a1;8a2;8b1;8b3;		2		1	40	40	2			2	
H7728	005	0	1	04	01	H7728_005_0	5	5	PCP	01	7a;7g;		2		2			1	35.00	35.00	2	
H7728	005	0	1	04	01	H7728_005_0	5	6	Specialist	11	7b;7c;7d;7e;7f;7h;7i;	7f;14b;	2		2			1	60.00	60.00	2	
H7728	005	0	1	04	01	H7728_005_0	5	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;14a;14d;14e;17a;18a;		2		1	40	40	2			2	
H7728	005	0	1	04	01	H7728_005_0	5	8	$0	10		14c;	1	95.00	2			1	0.00	0.00	2	
H7728	005	0	1	04	01	H7728_005_0	5	9	35% Coinsurance	01	11a;11b;11c;		2		1	35	35	2			2	
H7728	801	0	1	04	01	H7728_801_0	1	1		01	6;14a;		2		1	0	0	2			2	
H7728	801	0	1	04	01	H7728_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H7728	802	0	1	04	01	H7728_802_0	1	1		01	6;14a;		2		1	0	0	2			2	
H7728	802	0	1	04	01	H7728_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H7728	803	0	1	04	01	H7728_803_0	1	1		01	6;14a;		2		1	0	0	2			2	
H7728	803	0	1	04	01	H7728_803_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H7728	804	0	2	04	01	H7728_804_0	1	1		01	6;14a;		2		1	0	0	2			2	
H7728	804	0	2	04	01	H7728_804_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H7787	001	0	1	04	01	H7787_001_0	3	1	50% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;16b;17a;17b;18a;	9d;16a;17b;18a;18b;	2		1	50	50	2			2	
H7787	001	0	1	04	01	H7787_001_0	3	2	Ambulance	01	10a;		2		1	20	20	1	170.00	170.00	2	
H7787	001	0	1	04	01	H7787_001_0	3	3	25% Coinsurance	01	15;		2		1	25	25	2			2	
H7787	001	0	1	04	01	H7787_001_0	3	4	$0 Cost Share	10		14c;17a;	2		2			2			2	
H7787	002	0	1	04	01	H7787_002_0	3	1	50% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;16b;17a;17b;18a;	9d;16a;18a;18b;	2		1	50	50	2			2	
H7787	002	0	1	04	01	H7787_002_0	3	2	Ambulance	01	10a;		2		1	20	20	1	150.00	150.00	2	
H7787	002	0	1	04	01	H7787_002_0	3	3	25% Coinsurance	01	15;		2		1	25	25	2			2	
H7787	002	0	1	04	01	H7787_002_0	3	4	$0 Cost Share	10		14c;	2		2			2			2	
H7917	008	0	1	04	01	H7917_008_0	5	1	50% Cost Share Group	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14a;15;16b;		2		1	50	50	2			2	
H7917	008	0	1	04	01	H7917_008_0	5	10	NonMedicare Covered EyeExams and EyeWear	10		17a;17b;	2		2			1	0.00	0.00	2	
H7917	008	0	1	04	01	H7917_008_0	5	2	Ambulance	01	10a;		2		1	20	20	1	150.00	150.00	2	
H7917	008	0	1	04	01	H7917_008_0	5	3	$0 Cost Share	11	9d;17b;	9d;14c;16a;	2		2			2			2	
H7917	008	0	1	04	01	H7917_008_0	5	4	$30 Cost Share	01	17a;		2		2			1	30.00	30.00	2	
H7917	008	0	1	04	01	H7917_008_0	5	5	20% Cost Share	01	11c;12;14d;		2		1	20	20	2			2	
H7917	008	0	1	04	01	H7917_008_0	5	6	$10 Copay	01	18a;		2		2			1	10.00	10.00	2	
H7917	008	0	1	04	01	H7917_008_0	5	7	Hearing Aids	10		18b;	2		2			1	599.00	899.00	2	
H7917	008	0	1	04	01	H7917_008_0	5	8	Medicare-Covered Preventive Services	01	14e;		2		1	20	50	2			2	
H7917	008	0	1	04	01	H7917_008_0	5	9	$45 Copay	10		18a;	2		2			1	45.00	45.00	2	
H7917	009	0	1	04	01	H7917_009_0	7	1	50% Cost Share Group	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14a;15;16b;		2		1	50	50	2			2	
H7917	009	0	1	04	01	H7917_009_0	7	10	NonMedicare Covered EyeExams and EyeWear	10		17a;17b;	2		2			1	0.00	0.00	2	
H7917	009	0	1	04	01	H7917_009_0	7	2	Ambulance	01	10a;		2		1	20	20	1	150.00	150.00	2	
H7917	009	0	1	04	01	H7917_009_0	7	3	$0 Cost Share	11	9d;17b;	9d;14c;16a;	2		2			2			2	
H7917	009	0	1	04	01	H7917_009_0	7	4	$30 Cost Share	01	17a;		2		2			1	30.00	30.00	2	
H7917	009	0	1	04	01	H7917_009_0	7	5	20% Cost Share	01	11c;12;14d;		2		1	20	20	2			2	
H7917	009	0	1	04	01	H7917_009_0	7	6	$10 Copay	01	18a;		2		2			1	10.00	10.00	2	
H7917	009	0	1	04	01	H7917_009_0	7	7	Hearing Aids	10		18b;	2		2			1	599.00	899.00	2	
H7917	009	0	1	04	01	H7917_009_0	7	8	Medicare-Covered Preventive Services	01	14e;		2		1	20	50	2			2	
H7917	009	0	1	04	01	H7917_009_0	7	9	$45 Copay	10		18a;	2		2			1	45.00	45.00	2	
H7917	010	0	1	04	01	H7917_010_0	7	1	50% Cost Share Group	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14a;15;16b;		2		1	50	50	2			2	
H7917	010	0	1	04	01	H7917_010_0	7	10	NonMedicare Covered EyeExams and EyeWear	10		17a;17b;	2		2			1	0.00	0.00	2	
H7917	010	0	1	04	01	H7917_010_0	7	2	Ambulance	01	10a;		2		1	20	20	1	150.00	150.00	2	
H7917	010	0	1	04	01	H7917_010_0	7	3	$0 Cost Share	11	9d;17b;	9d;14c;16a;	2		2			2			2	
H7917	010	0	1	04	01	H7917_010_0	7	4	$30 Cost Share	01	17a;		2		2			1	30.00	30.00	2	
H7917	010	0	1	04	01	H7917_010_0	7	5	20% Cost Share	01	11c;12;14d;		2		1	20	20	2			2	
H7917	010	0	1	04	01	H7917_010_0	7	6	$10 Copay	01	18a;		2		2			1	10.00	10.00	2	
H7917	010	0	1	04	01	H7917_010_0	7	7	Hearing Aids	10		18b;	2		2			1	599.00	899.00	2	
H7917	010	0	1	04	01	H7917_010_0	7	8	Medicare-Covered Preventive Services	01	14e;		2		1	20	50	2			2	
H7917	010	0	1	04	01	H7917_010_0	7	9	$45 Copay	10		18a;	2		2			1	45.00	45.00	2	
H7917	011	0	1	04	01	H7917_011_0	8	1	50% Cost Share Group	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14a;15;16b;		2		1	50	50	2			2	
H7917	011	0	1	04	01	H7917_011_0	8	10	NonMedicare Covered EyeExams and EyeWear	10		17a;17b;	2		2			1	0.00	0.00	2	
H7917	011	0	1	04	01	H7917_011_0	8	2	Ambulance	01	10a;		2		1	20	20	1	150.00	150.00	2	
H7917	011	0	1	04	01	H7917_011_0	8	3	$0 Cost Share	11	9d;17b;	9d;14c;16a;	2		2			2			2	
H7917	011	0	1	04	01	H7917_011_0	8	4	$30 Cost Share	01	17a;		2		2			1	30.00	30.00	2	
H7917	011	0	1	04	01	H7917_011_0	8	5	20% Cost Share	01	11c;12;14d;		2		1	20	20	2			2	
H7917	011	0	1	04	01	H7917_011_0	8	6	$10 Copay	01	18a;		2		2			1	10.00	10.00	2	
H7917	011	0	1	04	01	H7917_011_0	8	7	Hearing Aids	10		18b;	2		2			1	599.00	899.00	2	
H7917	011	0	1	04	01	H7917_011_0	8	8	Medicare-Covered Preventive Services	01	14e;		2		1	20	50	2			2	
H7917	011	0	1	04	01	H7917_011_0	8	9	$45 Copay	10		18a;	2		2			1	45.00	45.00	2	
H7917	012	0	1	04	01	H7917_012_0	8	1	50% Cost Share Group	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14a;15;16b;		2		1	50	50	2			2	
H7917	012	0	1	04	01	H7917_012_0	8	10	NonMedicare Covered EyeExams and EyeWear	10		17a;17b;	2		2			1	0.00	0.00	2	
H7917	012	0	1	04	01	H7917_012_0	8	2	Ambulance	01	10a;		2		1	20	20	1	150.00	150.00	2	
H7917	012	0	1	04	01	H7917_012_0	8	3	$0 Cost Share	11	9d;17b;	9d;14c;16a;	2		2			2			2	
H7917	012	0	1	04	01	H7917_012_0	8	4	$40 Cost Share	01	17a;		2		2			1	40.00	40.00	2	
H7917	012	0	1	04	01	H7917_012_0	8	5	20% Cost Share	01	11c;12;14d;		2		1	20	20	2			2	
H7917	012	0	1	04	01	H7917_012_0	8	6	$10 Copay	01	18a;		2		2			1	10.00	10.00	2	
H7917	012	0	1	04	01	H7917_012_0	8	7	Hearing Aids	10		18b;	2		2			1	599.00	899.00	2	
H7917	012	0	1	04	01	H7917_012_0	8	8	Medicare-Covered Preventive Services	01	14e;		2		1	20	50	2			2	
H7917	012	0	1	04	01	H7917_012_0	8	9	$45 Copay	10		18a;	2		2			1	45.00	45.00	2	
H7917	013	0	1	04	01	H7917_013_0	8	1	50% Cost Share Group	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14a;15;16b;		2		1	50	50	2			2	
H7917	013	0	1	04	01	H7917_013_0	8	10	NonMedicare Covered EyeExams and EyeWear	10		17a;17b;	2		2			1	0.00	0.00	2	
H7917	013	0	1	04	01	H7917_013_0	8	2	Ambulance	01	10a;		2		1	20	20	1	150.00	150.00	2	
H7917	013	0	1	04	01	H7917_013_0	8	3	$0 Cost Share	11	9d;17b;	9d;14c;16a;	2		2			2			2	
H7917	013	0	1	04	01	H7917_013_0	8	4	$40 Cost Share	01	17a;		2		2			1	40.00	40.00	2	
H7917	013	0	1	04	01	H7917_013_0	8	5	20% Cost Share	01	11c;12;14d;		2		1	20	20	2			2	
H7917	013	0	1	04	01	H7917_013_0	8	6	$10 Copay	01	18a;		2		2			1	10.00	10.00	2	
H7917	013	0	1	04	01	H7917_013_0	8	7	Hearing Aids	10		18b;	2		2			1	599.00	899.00	2	
H7917	013	0	1	04	01	H7917_013_0	8	8	Medicare-Covered Preventive Services	01	14e;		2		1	20	50	2			2	
H7917	013	0	1	04	01	H7917_013_0	8	9	$45 Copay	10		18a;	2		2			1	45.00	45.00	2	
H7917	014	0	1	04	01	H7917_014_0	8	1	50% Cost Share Group	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14a;15;16b;		2		1	50	50	2			2	
H7917	014	0	1	04	01	H7917_014_0	8	10	NonMedicare Covered EyeExams and EyeWear	10		17a;17b;	2		2			1	0.00	0.00	2	
H7917	014	0	1	04	01	H7917_014_0	8	2	Ambulance	01	10a;		2		1	20	20	1	150.00	150.00	2	
H7917	014	0	1	04	01	H7917_014_0	8	3	$0 Cost Share	11	9d;17b;	9d;14c;16a;	2		2			2			2	
H7917	014	0	1	04	01	H7917_014_0	8	4	$40 Cost Share	01	17a;		2		2			1	40.00	40.00	2	
H7917	014	0	1	04	01	H7917_014_0	8	5	20% Cost Share	01	11c;12;14d;		2		1	20	20	2			2	
H7917	014	0	1	04	01	H7917_014_0	8	6	$10 Copay	01	18a;		2		2			1	10.00	10.00	2	
H7917	014	0	1	04	01	H7917_014_0	8	7	Hearing Aids	10		18b;	2		2			1	599.00	899.00	2	
H7917	014	0	1	04	01	H7917_014_0	8	8	Medicare-Covered Preventive Services	01	14e;		2		1	20	50	2			2	
H7917	014	0	1	04	01	H7917_014_0	8	9	$45 Copay	10		18a;	2		2			1	45.00	45.00	2	
H7917	015	0	1	04	01	H7917_015_0	8	1	50% Cost Share Group	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14a;15;16b;		2		1	50	50	2			2	
H7917	015	0	1	04	01	H7917_015_0	8	10	NonMedicare Covered EyeExams and EyeWear	10		17a;17b;	2		2			1	0.00	0.00	2	
H7917	015	0	1	04	01	H7917_015_0	8	2	Ambulance	01	10a;		2		1	20	20	1	150.00	150.00	2	
H7917	015	0	1	04	01	H7917_015_0	8	3	$0 Cost Share	11	9d;17b;	9d;14c;16a;	2		2			2			2	
H7917	015	0	1	04	01	H7917_015_0	8	4	$40 Cost Share	01	17a;		2		2			1	40.00	40.00	2	
H7917	015	0	1	04	01	H7917_015_0	8	5	20% Cost Share	01	11c;12;14d;		2		1	20	20	2			2	
H7917	015	0	1	04	01	H7917_015_0	8	6	$10 Copay	01	18a;		2		2			1	10.00	10.00	2	
H7917	015	0	1	04	01	H7917_015_0	8	7	Hearing Aids	10		18b;	2		2			1	599.00	899.00	2	
H7917	015	0	1	04	01	H7917_015_0	8	8	Medicare-Covered Preventive Services	01	14e;		2		1	20	50	2			2	
H7917	015	0	1	04	01	H7917_015_0	8	9	$45 Copay	10		18a;	2		2			1	45.00	45.00	2	
H7917	030	0	1	04	01	H7917_030_0	8	1	50% Cost Share Group	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14a;15;16b;		2		1	50	50	2			2	
H7917	030	0	1	04	01	H7917_030_0	8	10	NonMedicare Covered EyeExams and EyeWear	10		17a;17b;	2		2			1	0.00	0.00	2	
H7917	030	0	1	04	01	H7917_030_0	8	2	Ambulance	01	10a;		2		1	20	20	1	250.00	250.00	2	
H7917	030	0	1	04	01	H7917_030_0	8	3	$0 Cost Share	11	9d;17b;	9d;14c;16a;	2		2			2			2	
H7917	030	0	1	04	01	H7917_030_0	8	4	$40 Cost Share	01	17a;		2		2			1	40.00	40.00	2	
H7917	030	0	1	04	01	H7917_030_0	8	5	20% Cost Share	01	11c;12;14d;		2		1	20	20	2			2	
H7917	030	0	1	04	01	H7917_030_0	8	6	$10 Copay	01	18a;		2		2			1	10.00	10.00	2	
H7917	030	0	1	04	01	H7917_030_0	8	7	Hearing Aids	10		18b;	2		2			1	599.00	899.00	2	
H7917	030	0	1	04	01	H7917_030_0	8	8	Medicare-Covered Preventive Services	01	14e;		2		1	20	50	2			2	
H7917	030	0	1	04	01	H7917_030_0	8	9	$45 Copay	10		18a;	2		2			1	45.00	45.00	2	
H7917	031	0	1	04	01	H7917_031_0	8	1	50% Cost Share Group	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14a;15;16b;		2		1	50	50	2			2	
H7917	031	0	1	04	01	H7917_031_0	8	10	NonMedicare Covered EyeExams and EyeWear	10		17a;17b;	2		2			1	0.00	0.00	2	
H7917	031	0	1	04	01	H7917_031_0	8	2	Ambulance	01	10a;		2		1	20	20	1	250.00	250.00	2	
H7917	031	0	1	04	01	H7917_031_0	8	3	$0 Cost Share	11	9d;17b;	9d;14c;16a;	2		2			2			2	
H7917	031	0	1	04	01	H7917_031_0	8	4	$40 Cost Share	01	17a;		2		2			1	40.00	40.00	2	
H7917	031	0	1	04	01	H7917_031_0	8	5	20% Cost Share	01	11c;12;14d;		2		1	20	20	2			2	
H7917	031	0	1	04	01	H7917_031_0	8	6	$10 Copay	01	18a;		2		2			1	10.00	10.00	2	
H7917	031	0	1	04	01	H7917_031_0	8	7	Hearing Aids	10		18b;	2		2			1	599.00	899.00	2	
H7917	031	0	1	04	01	H7917_031_0	8	8	Medicare-Covered Preventive Services	01	14e;		2		1	20	50	2			2	
H7917	031	0	1	04	01	H7917_031_0	8	9	$45 Copay	10		18a;	2		2			1	45.00	45.00	2	
H7917	032	0	1	04	01	H7917_032_0	8	1	50% Cost Share Group	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14a;15;16b;		2		1	50	50	2			2	
H7917	032	0	1	04	01	H7917_032_0	8	10	NonMedicare Covered EyeExams and EyeWear	10		17a;17b;	2		2			1	0.00	0.00	2	
H7917	032	0	1	04	01	H7917_032_0	8	2	Ambulance	01	10a;		2		1	20	20	1	250.00	250.00	2	
H7917	032	0	1	04	01	H7917_032_0	8	3	$0 Cost Share	11	9d;17b;	9d;14c;16a;	2		2			2			2	
H7917	032	0	1	04	01	H7917_032_0	8	4	$40 Cost Share	01	17a;		2		2			1	40.00	40.00	2	
H7917	032	0	1	04	01	H7917_032_0	8	5	20% Cost Share	01	11c;12;14d;		2		1	20	20	2			2	
H7917	032	0	1	04	01	H7917_032_0	8	6	$10 Copay	01	18a;		2		2			1	10.00	10.00	2	
H7917	032	0	1	04	01	H7917_032_0	8	7	Hearing Aids	10		18b;	2		2			1	599.00	899.00	2	
H7917	032	0	1	04	01	H7917_032_0	8	8	Medicare-Covered Preventive Services	01	14e;		2		1	20	50	2			2	
H7917	032	0	1	04	01	H7917_032_0	8	9	$45 Copay	10		18a;	2		2			1	45.00	45.00	2	
H7917	033	0	1	04	01	H7917_033_0	8	1	50% Cost Share Group	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14a;15;16b;		2		1	50	50	2			2	
H7917	033	0	1	04	01	H7917_033_0	8	10	NonMedicare Covered EyeExams and EyeWear	10		17a;17b;	2		2			1	0.00	0.00	2	
H7917	033	0	1	04	01	H7917_033_0	8	2	Ambulance	01	10a;		2		1	20	20	1	250.00	250.00	2	
H7917	033	0	1	04	01	H7917_033_0	8	3	$0 Cost Share	11	9d;17b;	9d;14c;16a;	2		2			2			2	
H7917	033	0	1	04	01	H7917_033_0	8	4	$40 Cost Share	01	17a;		2		2			1	40.00	40.00	2	
H7917	033	0	1	04	01	H7917_033_0	8	5	20% Cost Share	01	11c;12;14d;		2		1	20	20	2			2	
H7917	033	0	1	04	01	H7917_033_0	8	6	$10 Copay	01	18a;		2		2			1	10.00	10.00	2	
H7917	033	0	1	04	01	H7917_033_0	8	7	Hearing Aids	10		18b;	2		2			1	599.00	899.00	2	
H7917	033	0	1	04	01	H7917_033_0	8	8	Medicare-Covered Preventive Services	01	14e;		2		1	20	50	2			2	
H7917	033	0	1	04	01	H7917_033_0	8	9	$45 Copay	10		18a;	2		2			1	45.00	45.00	2	
H7917	801	0	1	04	01	H7917_801_0	3	1		01	6;14a;		2		1	0	0	2			2	
H7917	801	0	1	04	01	H7917_801_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H7917	802	0	1	04	01	H7917_802_0	3	1		01	6;14a;		2		1	0	0	2			2	
H7917	802	0	1	04	01	H7917_802_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H7917	803	0	1	04	01	H7917_803_0	3	1		01	6;14a;		2		1	0	0	2			2	
H7917	803	0	1	04	01	H7917_803_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H7971	001	0	1	04	01	H7971_001_0	7	1		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;17a;	2		1	35	35	2			2	
H7971	001	0	1	04	01	H7971_001_0	7	2		10		17b;	2		2			2			2	
H7971	001	0	1	04	01	H7971_001_0	7	3		10		14c;	1	200.00	2			2			2	
H7971	801	0	1	04	01	H7971_801_0	1	1		01	6;14a;		2		1	0	0	2			2	
H7971	801	0	1	04	01	H7971_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H7971	802	0	1	04	01	H7971_802_0	1	1		01	6;14a;		2		1	0	0	2			2	
H7971	802	0	1	04	01	H7971_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H7971	805	0	1	04	01	H7971_805_0	2	1		01	6;14a;		2		1	0	0	2			2	
H7971	805	0	1	04	01	H7971_805_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H7971	806	0	1	04	01	H7971_806_0	1	1		01	6;14a;		2		1	0	0	2			2	
H7971	806	0	1	04	01	H7971_806_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H8003	001	0	1	04	01	H8003_001_0	3	1	20% Coinsurance Group	11	3-1;3-2;3-3;6;8a1;8b2;9a;9b;11c;12;15;	14b;	2		1	20	20	2			2	
H8003	001	0	1	04	01	H8003_001_0	3	10	Eyewear Allowance	10		17b;	2		2			2			2	
H8003	001	0	1	04	01	H8003_001_0	3	11	Supplemental Benefits - Fitness Center	10		14c;	2		2			2			2	
H8003	001	0	1	04	01	H8003_001_0	3	12	Eye Exam	01	17a;		2		2			1	0.00	50.00	2	
H8003	001	0	1	04	01	H8003_001_0	3	13	$40 Group	01	7b;		2		2			1	40.00	40.00	2	
H8003	001	0	1	04	01	H8003_001_0	3	14	$150 Group	01	8b1;		2		2			1	150.00	150.00	2	
H8003	001	0	1	04	01	H8003_001_0	3	15	Eyewear	01	17b;		2		2			2			2	
H8003	001	0	1	04	01	H8003_001_0	3	2	$55 Copayment Group	01	5;7c;7d;7e;7f;7g;7h;7i;9c;		2		2			1	55.00	55.00	2	
H8003	001	0	1	04	01	H8003_001_0	3	3	30% Coinsurance Group	01	11a;11b;		2		1	30	30	2			2	
H8003	001	0	1	04	01	H8003_001_0	3	4	$30 Copayment Group	01	7a;		2		2			1	30.00	30.00	2	
H8003	001	0	1	04	01	H8003_001_0	3	5	$15 Copayment Group	01	8a2;8b3;		2		2			1	15.00	15.00	2	
H8003	001	0	1	04	01	H8003_001_0	3	6	$50 Copayment Group	11	9d;14d;14e;16b;18a;	9d;	2		2			1	50.00	50.00	2	
H8003	001	0	1	04	01	H8003_001_0	3	7	Ambulance Services	01	10a;		2		2			1	275.00	275.00	2	
H8003	001	0	1	04	01	H8003_001_0	3	8	Preventive	01	14a;		2		2			1	0.00	0.00	2	
H8003	001	0	1	04	01	H8003_001_0	3	9	Preventive Dental Allowance	10		16a;	1	150.00	2			2			2	
H8003	002	0	1	04	01	H8003_002_0	3	1	20% Coinsurance Group	11	3-1;3-2;3-3;6;8a1;8b2;9a;9b;11c;12;15;	14b;	2		1	20	20	2			2	
H8003	002	0	1	04	01	H8003_002_0	3	10	Eyewear Allowance	10		17b;	2		2			2			2	
H8003	002	0	1	04	01	H8003_002_0	3	11	Supplemental Benefits - Fitness Center	10		14c;	2		2			2			2	
H8003	002	0	1	04	01	H8003_002_0	3	12	Eye Exam	01	17a;		2		2			1	0.00	50.00	2	
H8003	002	0	1	04	01	H8003_002_0	3	13	$40 Group	01	7b;		2		2			1	40.00	40.00	2	
H8003	002	0	1	04	01	H8003_002_0	3	14	$150 Group	01	8b1;		2		2			1	150.00	150.00	2	
H8003	002	0	1	04	01	H8003_002_0	3	15	Eyewear	01	17b;		2		2			2			2	
H8003	002	0	1	04	01	H8003_002_0	3	2	$55 Copayment Group	01	5;7c;7d;7e;7f;7g;7h;7i;9c;		2		2			1	55.00	55.00	2	
H8003	002	0	1	04	01	H8003_002_0	3	3	30% Coinsurance Group	01	11a;11b;		2		1	30	30	2			2	
H8003	002	0	1	04	01	H8003_002_0	3	4	$30 Copayment Group	01	7a;		2		2			1	30.00	30.00	2	
H8003	002	0	1	04	01	H8003_002_0	3	5	$15 Copayment Group	01	8a2;8b3;		2		2			1	15.00	15.00	2	
H8003	002	0	1	04	01	H8003_002_0	3	6	$50 Copayment Group	11	9d;14d;14e;16b;18a;	9d;	2		2			1	50.00	50.00	2	
H8003	002	0	1	04	01	H8003_002_0	3	7	Ambulance Services	01	10a;		2		2			1	275.00	275.00	2	
H8003	002	0	1	04	01	H8003_002_0	3	8	Preventive	01	14a;		2		2			1	0.00	0.00	2	
H8003	002	0	1	04	01	H8003_002_0	3	9	Preventive Dental Allowance	10		16a;	1	150.00	2			2			2	
H8003	003	0	1	04	01	H8003_003_0	3	1	20% Coinsurance Group	11	3-1;3-2;3-3;6;8a1;8b2;9a;9b;11c;12;15;	14b;	2		1	20	20	2			2	
H8003	003	0	1	04	01	H8003_003_0	3	10	Eyewear Allowance	10		17b;	2		2			2			2	
H8003	003	0	1	04	01	H8003_003_0	3	11	Supplemental Benefits - Fitness Center	10		14c;	2		2			2			2	
H8003	003	0	1	04	01	H8003_003_0	3	12	Eye Exam	01	17a;		2		2			1	0.00	50.00	2	
H8003	003	0	1	04	01	H8003_003_0	3	13	$40 Group	01	7b;		2		2			1	40.00	40.00	2	
H8003	003	0	1	04	01	H8003_003_0	3	14	$150 Group	01	8b1;		2		2			1	150.00	150.00	2	
H8003	003	0	1	04	01	H8003_003_0	3	15	Eyewear	01	17b;		2		2			2			2	
H8003	003	0	1	04	01	H8003_003_0	3	2	$55 Copayment Group	01	5;7c;7d;7e;7f;7g;7h;7i;9c;		2		2			1	55.00	55.00	2	
H8003	003	0	1	04	01	H8003_003_0	3	3	30% Coinsurance Group	01	11a;11b;		2		1	30	30	2			2	
H8003	003	0	1	04	01	H8003_003_0	3	4	$30 Copayment Group	01	7a;		2		2			1	30.00	30.00	2	
H8003	003	0	1	04	01	H8003_003_0	3	5	$15 Copayment Group	01	8a2;8b3;		2		2			1	15.00	15.00	2	
H8003	003	0	1	04	01	H8003_003_0	3	6	$50 Copayment Group	11	9d;14d;14e;16b;18a;	9d;	2		2			1	50.00	50.00	2	
H8003	003	0	1	04	01	H8003_003_0	3	7	Ambulance Services	01	10a;		2		2			1	275.00	275.00	2	
H8003	003	0	1	04	01	H8003_003_0	3	8	Preventive	01	14a;		2		2			1	0.00	0.00	2	
H8003	003	0	1	04	01	H8003_003_0	3	9	Preventive Dental Allowance	10		16a;	1	150.00	2			2			2	
H8003	801	0	1	04	01	H8003_801_0	1	1		01	6;14a;		2		1	0	0	2			2	
H8003	801	0	1	04	01	H8003_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H8003	802	0	1	04	01	H8003_802_0	1	1		01	6;14a;		2		1	0	0	2			2	
H8003	802	0	1	04	01	H8003_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H8003	803	0	1	04	01	H8003_803_0	1	1		01	6;14a;		2		1	0	0	2			2	
H8003	803	0	1	04	01	H8003_803_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H8003	804	0	1	04	01	H8003_804_0	1	1		01	6;14a;		2		1	0	0	2			2	
H8003	804	0	1	04	01	H8003_804_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H8064	002	0	1	04	01	H8064_002_0	4	1	20 PCT COINSURANCE	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;15;16b;17a;17b;18a;	17a;	2		1	20	20	2			2	
H8064	002	0	1	04	01	H8064_002_0	4	2	0 COPAY	11	14a;14d;14e;	14b;	2		2			1	0.00	0.00	2	
H8064	002	0	1	04	01	H8064_002_0	4	3	15 PCT COINSURANCE	01	6;		2		1	15	15	2			2	
H8064	002	0	1	04	01	H8064_002_0	4	4	250 Copay	01	10a;		2		2			1	250.00	250.00	2	
H8064	002	0	1	04	01	H8064_002_0	4	5	Supplemental	10		14c;	1	300.00	2			2			2	
H8064	002	0	1	04	01	H8064_002_0	4	6	30 PCT COINSURANCE	01	8a1;8a2;8b1;8b2;8b3;		2		1	30	30	2			2	
H8145	003	0	1	09	04	H8145_003_0	5	1		11	6;9d;14a;14d;14e;	9d;14b;	2		2			1	0.00	0.00	2	
H8145	003	0	1	09	04	H8145_003_0	5	10		01	8b1;				2			1	45.00	345.00	2	
H8145	003	0	1	09	04	H8145_003_0	5	11		01	7d;7f;16b;18a;				2			1	45.00	45.00	2	
H8145	003	0	1	09	04	H8145_003_0	5	12		01	11a;11b;11c;12;15;				1	20	20	2			2	
H8145	003	0	1	09	04	H8145_003_0	5	13		01	10a;				1	20	20	1	265.00	265.00	2	
H8145	003	0	1	09	04	H8145_003_0	5	14		01	8b2;				1	20	20	1	45.00	45.00	2	
H8145	003	0	1	09	04	H8145_003_0	5	15		10		13c;14c;	2		1	50	50	2			2	
H8145	003	0	1	09	04	H8145_003_0	5	2		01	8a1;8a2;17a;				2			1	0.00	105.00	2	
H8145	003	0	1	09	04	H8145_003_0	5	3		01	7c;7g;7i;8b3;				2			1	15.00	100.00	2	
H8145	003	0	1	09	04	H8145_003_0	5	4		01	3-1;3-2;3-3;7a;				2			1	15.00	15.00	2	
H8145	003	0	1	09	04	H8145_003_0	5	5		01	7b;				2			1	20.00	20.00	2	
H8145	003	0	1	09	04	H8145_003_0	5	6		01	17b;				2			1	25.00	25.00	2	
H8145	003	0	1	09	04	H8145_003_0	5	7		01	9b;				2			1	295.00	295.00	2	
H8145	003	0	1	09	04	H8145_003_0	5	8		01	9a;				2			1	345.00	345.00	2	
H8145	003	0	1	09	04	H8145_003_0	5	9		01	5;7e;7h;9c;				2			1	40.00	105.00	2	
H8145	004	0	1	09	04	H8145_004_0	5	1		11	6;9d;14a;14d;14e;	9d;14b;	2		2			1	0.00	0.00	2	
H8145	004	0	1	09	04	H8145_004_0	5	10		01	8b1;				2			1	45.00	345.00	2	
H8145	004	0	1	09	04	H8145_004_0	5	11		01	7d;7f;16b;18a;				2			1	45.00	45.00	2	
H8145	004	0	1	09	04	H8145_004_0	5	12		01	11a;11b;11c;12;15;				1	20	20	2			2	
H8145	004	0	1	09	04	H8145_004_0	5	13		01	10a;				1	20	20	1	265.00	265.00	2	
H8145	004	0	1	09	04	H8145_004_0	5	14		01	8b2;				1	20	20	1	45.00	45.00	2	
H8145	004	0	1	09	04	H8145_004_0	5	15		10		13c;14c;	2		1	50	50	2			2	
H8145	004	0	1	09	04	H8145_004_0	5	2		01	8a1;8a2;17a;				2			1	0.00	105.00	2	
H8145	004	0	1	09	04	H8145_004_0	5	3		01	7c;7g;7i;8b3;				2			1	15.00	100.00	2	
H8145	004	0	1	09	04	H8145_004_0	5	4		01	3-1;3-2;3-3;7a;				2			1	15.00	15.00	2	
H8145	004	0	1	09	04	H8145_004_0	5	5		01	7b;				2			1	20.00	20.00	2	
H8145	004	0	1	09	04	H8145_004_0	5	6		01	17b;				2			1	25.00	25.00	2	
H8145	004	0	1	09	04	H8145_004_0	5	7		01	9b;				2			1	295.00	295.00	2	
H8145	004	0	1	09	04	H8145_004_0	5	8		01	9a;				2			1	345.00	345.00	2	
H8145	004	0	1	09	04	H8145_004_0	5	9		01	5;7e;7h;9c;				2			1	40.00	105.00	2	
H8145	006	0	1	09	04	H8145_006_0	4	1		11	9d;14a;14d;14e;	9d;14b;17a;18b;	2		2			1	0.00	0.00	2	
H8145	006	0	1	09	04	H8145_006_0	4	10		01	5;				2			1	55.00	55.00	2	
H8145	006	0	1	09	04	H8145_006_0	4	11		01	6;8b2;9b;10a;11a;11b;11c;12;15;				1	20	20	2			2	
H8145	006	0	1	09	04	H8145_006_0	4	12		01	8b1;				1	20	25	1	20.00	75.00	2	
H8145	006	0	1	09	04	H8145_006_0	4	13		01	9a;				1	25	25	2			2	
H8145	006	0	1	09	04	H8145_006_0	4	14		10		13c;14c;16a;16b;18a;	2		1	50	50	2			2	
H8145	006	0	1	09	04	H8145_006_0	4	15		10		13b;	1	15.00	1	50	50	2			2	
H8145	006	0	1	09	04	H8145_006_0	4	2		01	8a2;				2			1	0.00	40.00	2	
H8145	006	0	1	09	04	H8145_006_0	4	3		01	8a1;17a;				2			1	0.00	95.00	2	
H8145	006	0	1	09	04	H8145_006_0	4	4		01	3-1;3-2;7a;7b;17b;				2			1	20.00	20.00	2	
H8145	006	0	1	09	04	H8145_006_0	4	5		01	8b3;				2			1	20.00	95.00	2	
H8145	006	0	1	09	04	H8145_006_0	4	6		01	3-3;				2			1	30.00	30.00	2	
H8145	006	0	1	09	04	H8145_006_0	4	7		01	7c;7e;7h;7i;				2			1	40.00	40.00	2	
H8145	006	0	1	09	04	H8145_006_0	4	8		01	9c;				2			1	40.00	95.00	2	
H8145	006	0	1	09	04	H8145_006_0	4	9		01	7d;7f;7g;16b;18a;				2			1	50.00	50.00	2	
H8145	008	0	1	09	04	H8145_008_0	4	1		11	9d;	9d;17a;	2		2			1	0.00	0.00	2	
H8145	008	0	1	09	04	H8145_008_0	4	2		01	8b2;10a;12;				1	20	20	2			2	
H8145	008	0	1	09	04	H8145_008_0	4	3		01	11a;				1	40	40	2			2	
H8145	008	0	1	09	04	H8145_008_0	4	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;14b;14c;	2		1	50	50	2			2	
H8145	008	0	1	09	04	H8145_008_0	4	5		01	14a;				1	50	50	1	0.00	0.00	2	
H8145	011	0	1	09	04	H8145_011_0	5	1		11	6;9d;14a;14d;14e;	9d;14b;	2		2			1	0.00	0.00	2	
H8145	011	0	1	09	04	H8145_011_0	5	10		01	7d;7f;16b;17b;18a;				2			1	45.00	45.00	2	
H8145	011	0	1	09	04	H8145_011_0	5	11		01	11c;				1	10	20	2			2	
H8145	011	0	1	09	04	H8145_011_0	5	12		01	11a;11b;12;15;				1	20	20	2			2	
H8145	011	0	1	09	04	H8145_011_0	5	13		01	10a;				1	20	20	1	265.00	265.00	2	
H8145	011	0	1	09	04	H8145_011_0	5	14		01	8b2;				1	20	20	1	45.00	45.00	2	
H8145	011	0	1	09	04	H8145_011_0	5	15		10		13c;14c;	2		1	50	50	2			2	
H8145	011	0	1	09	04	H8145_011_0	5	2		01	8a1;17a;				2			1	0.00	105.00	2	
H8145	011	0	1	09	04	H8145_011_0	5	3		01	8a2;				2			1	0.00	35.00	2	
H8145	011	0	1	09	04	H8145_011_0	5	4		01	3-1;3-2;3-3;7a;7b;7c;7i;				2			1	20.00	40.00	2	
H8145	011	0	1	09	04	H8145_011_0	5	5		01	7g;8b3;				2			1	20.00	95.00	2	
H8145	011	0	1	09	04	H8145_011_0	5	6		01	9b;				2			1	365.00	365.00	2	
H8145	011	0	1	09	04	H8145_011_0	5	7		01	9a;				2			1	395.00	395.00	2	
H8145	011	0	1	09	04	H8145_011_0	5	8		01	5;7e;7h;9c;				2			1	40.00	105.00	2	
H8145	011	0	1	09	04	H8145_011_0	5	9		01	8b1;				2			1	45.00	395.00	2	
H8145	021	0	1	09	04	H8145_021_0	2	1		11	9d;	9d;	2		2			1	0.00	0.00	2	
H8145	021	0	1	09	04	H8145_021_0	2	2		01	17b;				2			1	25.00	25.00	2	
H8145	021	0	1	09	04	H8145_021_0	2	3		01	12;				1	20	20	2			2	
H8145	021	0	1	09	04	H8145_021_0	2	4		01	10a;				1	20	20	1	265.00	265.00	2	
H8145	021	0	1	09	04	H8145_021_0	2	5		01	15;				1	20	30	2			2	
H8145	021	0	1	09	04	H8145_021_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;16b;17a;18a;	14b;	2		1	30	30	2			2	
H8145	021	0	1	09	04	H8145_021_0	2	7		01	14a;				1	30	30	1	0.00	0.00	2	
H8145	021	0	1	09	04	H8145_021_0	2	8		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H8145	032	0	1	09	04	H8145_032_0	4	1		11	6;9d;14d;	9d;14b;	2		2			1	0.00	0.00	2	
H8145	032	0	1	09	04	H8145_032_0	4	10		01	8a1;8a2;14a;14e;17a;				1	30	30	1	0.00	50.00	2	
H8145	032	0	1	09	04	H8145_032_0	4	11		01	3-1;3-2;3-3;7c;7g;7i;8b3;				1	30	30	1	20.00	50.00	2	
H8145	032	0	1	09	04	H8145_032_0	4	12		01	9c;				1	30	30	1	40.00	40.00	2	
H8145	032	0	1	09	04	H8145_032_0	4	13		01	8b1;8b2;				1	30	30	1	50.00	395.00	2	
H8145	032	0	1	09	04	H8145_032_0	4	14		10		13c;14c;16a;	2		1	50	50	2			2	
H8145	032	0	1	09	04	H8145_032_0	4	15		10		16b;	2		1	50	80	2			2	
H8145	032	0	1	09	04	H8145_032_0	4	2		01	7a;7b;17b;				2			1	20.00	20.00	2	
H8145	032	0	1	09	04	H8145_032_0	4	3		01	9b;				2			1	365.00	365.00	2	
H8145	032	0	1	09	04	H8145_032_0	4	4		01	5;7e;7h;				2			1	40.00	40.00	2	
H8145	032	0	1	09	04	H8145_032_0	4	5		01	7d;7f;16b;18a;				2			1	50.00	50.00	2	
H8145	032	0	1	09	04	H8145_032_0	4	6		01	11c;				1	10	20	2			2	
H8145	032	0	1	09	04	H8145_032_0	4	7		01	11a;11b;12;15;				1	20	20	2			2	
H8145	032	0	1	09	04	H8145_032_0	4	8		01	10a;				1	20	20	1	265.00	265.00	2	
H8145	032	0	1	09	04	H8145_032_0	4	9		01	9a;				1	30	30	2			2	
H8145	042	0	1	09	04	H8145_042_0	5	1		11	6;9d;14a;14d;14e;	9d;14b;	2		2			1	0.00	0.00	2	
H8145	042	0	1	09	04	H8145_042_0	5	10		01	7d;7f;16b;18a;				2			1	45.00	45.00	2	
H8145	042	0	1	09	04	H8145_042_0	5	11		01	11a;11b;11c;12;15;				1	20	20	2			2	
H8145	042	0	1	09	04	H8145_042_0	5	12		01	10a;				1	20	20	1	265.00	265.00	2	
H8145	042	0	1	09	04	H8145_042_0	5	13		01	8b2;				1	20	20	1	45.00	45.00	2	
H8145	042	0	1	09	04	H8145_042_0	5	14		10		13c;14c;	2		1	50	50	2			2	
H8145	042	0	1	09	04	H8145_042_0	5	15		10		13b;	1	30.00	1	50	50	2			2	
H8145	042	0	1	09	04	H8145_042_0	5	2		01	8a1;8a2;17a;				2			1	0.00	105.00	2	
H8145	042	0	1	09	04	H8145_042_0	5	3		01	3-1;3-2;3-3;7a;7c;7g;7i;8b3;				2			1	15.00	100.00	2	
H8145	042	0	1	09	04	H8145_042_0	5	4		01	7b;				2			1	20.00	20.00	2	
H8145	042	0	1	09	04	H8145_042_0	5	5		01	17b;				2			1	25.00	25.00	2	
H8145	042	0	1	09	04	H8145_042_0	5	6		01	9b;				2			1	295.00	295.00	2	
H8145	042	0	1	09	04	H8145_042_0	5	7		01	9a;				2			1	345.00	345.00	2	
H8145	042	0	1	09	04	H8145_042_0	5	8		01	5;7e;7h;9c;				2			1	40.00	105.00	2	
H8145	042	0	1	09	04	H8145_042_0	5	9		01	8b1;				2			1	45.00	345.00	2	
H8145	050	0	1	09	04	H8145_050_0	3	1		11	6;9d;14a;14d;14e;	9d;14b;17a;17b;	2		2			1	0.00	0.00	2	
H8145	050	0	1	09	04	H8145_050_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8b1;8b2;8b3;9a;9b;9c;10a;11a;11b;11c;12;15;16b;17a;17b;18a;				1	20	20	2			2	
H8145	050	0	1	09	04	H8145_050_0	3	3		01	8a1;8a2;				1	20	20	1	0.00	0.00	2	
H8145	050	0	1	09	04	H8145_050_0	3	4		10		13c;14c;	2		1	50	50	2			2	
H8145	050	0	1	09	04	H8145_050_0	3	5		10		13b;	1	45.00	1	50	50	2			2	
H8145	051	0	1	09	04	H8145_051_0	2	1		11	6;9d;14a;14d;14e;	9d;14b;17a;17b;	2		2			1	0.00	0.00	2	
H8145	051	0	1	09	04	H8145_051_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8b1;8b2;8b3;9a;9b;9c;10a;11a;11b;11c;12;15;16b;17a;17b;18a;				1	20	20	2			2	
H8145	051	0	1	09	04	H8145_051_0	2	3		01	8a1;8a2;				1	20	20	1	0.00	0.00	2	
H8145	051	0	1	09	04	H8145_051_0	2	4		10		13c;14c;	2		1	50	50	2			2	
H8145	051	0	1	09	04	H8145_051_0	2	5		10		13b;	1	45.00	1	50	50	2			2	
H8145	052	0	1	09	04	H8145_052_0	2	1		11	6;9d;14a;14d;14e;	9d;14b;	2		2			1	0.00	0.00	2	
H8145	052	0	1	09	04	H8145_052_0	2	10		01	11c;				1	10	20	2			2	
H8145	052	0	1	09	04	H8145_052_0	2	11		01	11a;11b;12;15;				1	20	20	2			2	
H8145	052	0	1	09	04	H8145_052_0	2	12		01	10a;				1	20	20	1	250.00	250.00	2	
H8145	052	0	1	09	04	H8145_052_0	2	13		01	8b2;				1	20	20	1	45.00	45.00	2	
H8145	052	0	1	09	04	H8145_052_0	2	14		10		13c;14c;	2		1	50	50	2			2	
H8145	052	0	1	09	04	H8145_052_0	2	15		10		13b;	1	45.00	1	50	50	2			2	
H8145	052	0	1	09	04	H8145_052_0	2	2		01	8a1;8a2;17a;				2			1	0.00	105.00	2	
H8145	052	0	1	09	04	H8145_052_0	2	3		01	3-1;3-2;3-3;7a;7c;7g;7i;8b3;				2			1	15.00	100.00	2	
H8145	052	0	1	09	04	H8145_052_0	2	4		01	7b;				2			1	20.00	20.00	2	
H8145	052	0	1	09	04	H8145_052_0	2	5		01	9b;				2			1	245.00	245.00	2	
H8145	052	0	1	09	04	H8145_052_0	2	6		01	17b;				2			1	25.00	25.00	2	
H8145	052	0	1	09	04	H8145_052_0	2	7		01	9a;				2			1	295.00	295.00	2	
H8145	052	0	1	09	04	H8145_052_0	2	8		01	5;7e;7h;9c;				2			1	40.00	105.00	2	
H8145	052	0	1	09	04	H8145_052_0	2	9		01	7d;7f;8b1;16b;18a;				2			1	45.00	295.00	2	
H8145	055	0	1	09	04	H8145_055_0	1	1		11	6;9d;14a;14d;14e;	9d;14b;	2		2			1	0.00	0.00	2	
H8145	055	0	1	09	04	H8145_055_0	1	10		01	11c;				1	10	20	2			2	
H8145	055	0	1	09	04	H8145_055_0	1	11		01	11a;11b;12;15;				1	20	20	2			2	
H8145	055	0	1	09	04	H8145_055_0	1	12		01	10a;				1	20	20	1	265.00	265.00	2	
H8145	055	0	1	09	04	H8145_055_0	1	13		01	8b2;				1	20	20	1	45.00	45.00	2	
H8145	055	0	1	09	04	H8145_055_0	1	14		10		13c;14c;	2		1	50	50	2			2	
H8145	055	0	1	09	04	H8145_055_0	1	15		10		13b;	1	45.00	1	50	50	2			2	
H8145	055	0	1	09	04	H8145_055_0	1	2		01	8a1;8a2;17a;				2			1	0.00	105.00	2	
H8145	055	0	1	09	04	H8145_055_0	1	3		01	3-1;3-2;3-3;7a;7c;7i;8b3;				2			1	15.00	100.00	2	
H8145	055	0	1	09	04	H8145_055_0	1	4		01	7b;				2			1	20.00	20.00	2	
H8145	055	0	1	09	04	H8145_055_0	1	5		01	17b;				2			1	25.00	25.00	2	
H8145	055	0	1	09	04	H8145_055_0	1	6		01	9b;				2			1	300.00	300.00	2	
H8145	055	0	1	09	04	H8145_055_0	1	7		01	9a;				2			1	350.00	350.00	2	
H8145	055	0	1	09	04	H8145_055_0	1	8		01	5;7e;7h;9c;				2			1	40.00	105.00	2	
H8145	055	0	1	09	04	H8145_055_0	1	9		01	7d;7f;7g;8b1;16b;18a;				2			1	45.00	350.00	2	
H8145	061	0	1	09	04	H8145_061_0	4	1		11	6;9d;14a;14d;14e;	9d;14b;17a;	2		2			1	0.00	0.00	2	
H8145	061	0	1	09	04	H8145_061_0	4	10		01	7c;7i;9c;				1	20	25	1	40.00	40.00	2	
H8145	061	0	1	09	04	H8145_061_0	4	11		01	9a;				1	25	25	2			2	
H8145	061	0	1	09	04	H8145_061_0	4	12		01	8a1;8a2;				1	25	25	1	0.00	40.00	2	
H8145	061	0	1	09	04	H8145_061_0	4	13		01	3-1;3-2;3-3;				1	25	25	1	40.00	40.00	2	
H8145	061	0	1	09	04	H8145_061_0	4	14		10		13c;14c;	2		1	50	50	2			2	
H8145	061	0	1	09	04	H8145_061_0	4	15		10		13b;	1	10.00	1	50	50	2			2	
H8145	061	0	1	09	04	H8145_061_0	4	2		01	7a;				2			1	10.00	10.00	2	
H8145	061	0	1	09	04	H8145_061_0	4	3		01	7b;17b;				2			1	20.00	20.00	2	
H8145	061	0	1	09	04	H8145_061_0	4	4		01	7d;7e;7f;7g;7h;16b;17a;18a;				2			1	40.00	40.00	2	
H8145	061	0	1	09	04	H8145_061_0	4	5		01	5;9b;11a;11b;11c;12;15;				1	20	20	2			2	
H8145	061	0	1	09	04	H8145_061_0	4	6		01	10a;				1	20	20	1	265.00	265.00	2	
H8145	061	0	1	09	04	H8145_061_0	4	7		01	8b2;				1	20	20	1	40.00	40.00	2	
H8145	061	0	1	09	04	H8145_061_0	4	8		01	8b3;				1	20	25	1	10.00	40.00	2	
H8145	061	0	1	09	04	H8145_061_0	4	9		01	8b1;				1	20	25	1	40.00	150.00	2	
H8145	063	0	1	09	04	H8145_063_0	6	1		11	6;9d;14a;14d;14e;17b;	9d;14b;18a;	2		2			1	0.00	0.00	2	
H8145	063	0	1	09	04	H8145_063_0	6	10		10		18b;	2		2			1	699.00	999.00	2	
H8145	063	0	1	09	04	H8145_063_0	6	11		01	11a;11b;11c;12;15;				1	20	20	2			2	
H8145	063	0	1	09	04	H8145_063_0	6	12		01	7d;7g;8a1;8b2;				1	20	20	1	0.00	100.00	2	
H8145	063	0	1	09	04	H8145_063_0	6	13		01	10a;				1	20	20	1	265.00	265.00	2	
H8145	063	0	1	09	04	H8145_063_0	6	14		10		13c;14c;	2		1	50	50	2			2	
H8145	063	0	1	09	04	H8145_063_0	6	15		10		13b;	1	25.00	1	50	50	2			2	
H8145	063	0	1	09	04	H8145_063_0	6	2		01	8a2;8b3;17a;				2			1	0.00	100.00	2	
H8145	063	0	1	09	04	H8145_063_0	6	3		01	3-1;3-2;3-3;7a;7b;				2			1	20.00	20.00	2	
H8145	063	0	1	09	04	H8145_063_0	6	4		01	7c;7i;				2			1	20.00	40.00	2	
H8145	063	0	1	09	04	H8145_063_0	6	5		01	9a;9b;				2			1	350.00	400.00	2	
H8145	063	0	1	09	04	H8145_063_0	6	6		01	9c;				2			1	40.00	100.00	2	
H8145	063	0	1	09	04	H8145_063_0	6	7		01	5;7e;7h;				2			1	40.00	40.00	2	
H8145	063	0	1	09	04	H8145_063_0	6	8		01	8b1;				2			1	50.00	400.00	2	
H8145	063	0	1	09	04	H8145_063_0	6	9		01	7f;16b;18a;				2			1	50.00	50.00	2	
H8145	069	0	1	09	04	H8145_069_0	7	1		11	6;9d;14a;14d;14e;17b;	9d;14b;18a;	2		2			1	0.00	0.00	2	
H8145	069	0	1	09	04	H8145_069_0	7	10		01	7d;7f;16b;18a;				2			1	50.00	50.00	2	
H8145	069	0	1	09	04	H8145_069_0	7	11		10		18b;	2		2			1	699.00	999.00	2	
H8145	069	0	1	09	04	H8145_069_0	7	12		01	8b2;11a;11b;11c;12;15;				1	20	20	2			2	
H8145	069	0	1	09	04	H8145_069_0	7	13		01	10a;				1	20	20	1	265.00	265.00	2	
H8145	069	0	1	09	04	H8145_069_0	7	14		10		13c;14c;	2		1	50	50	2			2	
H8145	069	0	1	09	04	H8145_069_0	7	15		10		13b;	1	25.00	1	50	50	2			2	
H8145	069	0	1	09	04	H8145_069_0	7	2		01	8a1;8a2;17a;				2			1	0.00	100.00	2	
H8145	069	0	1	09	04	H8145_069_0	7	3		01	7c;7g;7i;8b3;				2			1	15.00	100.00	2	
H8145	069	0	1	09	04	H8145_069_0	7	4		01	3-1;3-2;3-3;7a;7b;				2			1	15.00	15.00	2	
H8145	069	0	1	09	04	H8145_069_0	7	5		01	9b;				2			1	345.00	345.00	2	
H8145	069	0	1	09	04	H8145_069_0	7	6		01	9a;				2			1	395.00	395.00	2	
H8145	069	0	1	09	04	H8145_069_0	7	7		01	9c;				2			1	40.00	100.00	2	
H8145	069	0	1	09	04	H8145_069_0	7	8		01	5;7e;7h;				2			1	40.00	40.00	2	
H8145	069	0	1	09	04	H8145_069_0	7	9		01	8b1;				2			1	50.00	395.00	2	
H8145	075	0	1	09	04	H8145_075_0	3	1		11	9d;	9d;17a;	2		2			1	0.00	0.00	2	
H8145	075	0	1	09	04	H8145_075_0	3	2		10		18a;	2		2			1	35.00	35.00	2	
H8145	075	0	1	09	04	H8145_075_0	3	3		01	10a;12;15;				1	20	20	2			2	
H8145	075	0	1	09	04	H8145_075_0	3	4		01	11a;11b;11c;				1	25	25	2			2	
H8145	075	0	1	09	04	H8145_075_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;17b;18a;	14b;	2		1	40	40	2			2	
H8145	075	0	1	09	04	H8145_075_0	3	6		01	14a;				1	40	40	1	0.00	0.00	2	
H8145	075	0	1	09	04	H8145_075_0	3	7		10		13c;14c;	2		1	50	50	2			2	
H8145	075	0	1	09	04	H8145_075_0	3	8		10		13b;	1	10.00	1	50	50	2			2	
H8145	084	0	1	09	04	H8145_084_0	3	1		11	9d;	9d;17a;	2		2			1	0.00	0.00	2	
H8145	084	0	1	09	04	H8145_084_0	3	10		10		13c;14c;	2		1	50	50	2			2	
H8145	084	0	1	09	04	H8145_084_0	3	2		01	7a;				2			1	20.00	20.00	2	
H8145	084	0	1	09	04	H8145_084_0	3	3		01	7b;7d;7e;7f;7g;7h;16b;17a;18a;				2			1	50.00	50.00	2	
H8145	084	0	1	09	04	H8145_084_0	3	4		01	11a;11b;11c;12;15;				1	20	20	2			2	
H8145	084	0	1	09	04	H8145_084_0	3	5		01	10a;				1	20	20	1	265.00	265.00	2	
H8145	084	0	1	09	04	H8145_084_0	3	6		11	5;6;8b2;9a;9b;14d;14e;17b;	14b;	2		1	30	30	2			2	
H8145	084	0	1	09	04	H8145_084_0	3	7		01	14a;				1	30	30	1	0.00	0.00	2	
H8145	084	0	1	09	04	H8145_084_0	3	8		01	8a1;8a2;8b3;				1	30	30	1	20.00	50.00	2	
H8145	084	0	1	09	04	H8145_084_0	3	9		01	3-1;3-2;3-3;7c;7i;8b1;9c;				1	30	30	1	50.00	50.00	2	
H8145	087	0	1	09	04	H8145_087_0	5	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
H8145	087	0	1	09	04	H8145_087_0	5	2		01	11a;11b;11c;12;15;				1	20	20	2			2	
H8145	087	0	1	09	04	H8145_087_0	5	3		01	10a;				1	20	20	1	265.00	265.00	2	
H8145	087	0	1	09	04	H8145_087_0	5	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	14b;	2		1	30	30	2			2	
H8145	087	0	1	09	04	H8145_087_0	5	5		01	14a;				1	30	30	1	0.00	0.00	2	
H8145	087	0	1	09	04	H8145_087_0	5	6		10		13c;14c;16a;	2		1	50	50	2			2	
H8145	087	0	1	09	04	H8145_087_0	5	7		10		13b;	1	30.00	1	50	50	2			2	
H8145	089	0	1	09	04	H8145_089_0	3	1		11	9d;	9d;	2		2			1	0.00	0.00	2	
H8145	089	0	1	09	04	H8145_089_0	3	2		01	11a;12;				1	20	20	2			2	
H8145	089	0	1	09	04	H8145_089_0	3	3		01	10a;				1	20	20	1	265.00	265.00	2	
H8145	089	0	1	09	04	H8145_089_0	3	4		01	11c;				1	20	30	2			2	
H8145	089	0	1	09	04	H8145_089_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;15;16b;17a;17b;18a;	14b;	2		1	30	30	2			2	
H8145	089	0	1	09	04	H8145_089_0	3	6		01	14a;				1	30	30	1	0.00	0.00	2	
H8145	089	0	1	09	04	H8145_089_0	3	7		10		13c;14c;	2		1	50	50	2			2	
H8145	091	0	1	09	04	H8145_091_0	4	1		11	9d;	9d;17a;	2		2			1	0.00	0.00	2	
H8145	091	0	1	09	04	H8145_091_0	4	2		10		18a;	2		2			1	35.00	35.00	2	
H8145	091	0	1	09	04	H8145_091_0	4	3		01	10a;11a;12;15;				1	20	20	2			2	
H8145	091	0	1	09	04	H8145_091_0	4	4		01	11c;				1	20	25	2			2	
H8145	091	0	1	09	04	H8145_091_0	4	5		01	11b;				1	25	25	2			2	
H8145	091	0	1	09	04	H8145_091_0	4	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;17b;18a;	14b;	2		1	35	35	2			2	
H8145	091	0	1	09	04	H8145_091_0	4	7		01	14a;				1	35	35	1	0.00	0.00	2	
H8145	091	0	1	09	04	H8145_091_0	4	8		10		13c;14c;	2		1	50	50	2			2	
H8145	091	0	1	09	04	H8145_091_0	4	9		10		13b;	1	10.00	1	50	50	2			2	
H8145	103	0	1	09	04	H8145_103_0	3	1		11	9d;14a;14d;14e;	9d;14b;17a;	2		2			1	0.00	0.00	2	
H8145	103	0	1	09	04	H8145_103_0	3	2		01	12;				1	20	20	2			2	
H8145	103	0	1	09	04	H8145_103_0	3	3		01	10a;				1	20	20	1	265.00	265.00	2	
H8145	103	0	1	09	04	H8145_103_0	3	4		01	11a;11b;11c;				1	40	40	2			2	
H8145	103	0	1	09	04	H8145_103_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;15;16b;17a;17b;18a;	13c;14c;	2		1	50	50	2			2	
H8145	103	0	1	09	04	H8145_103_0	3	6		10		13b;	1	50.00	1	50	50	2			2	
H8145	108	0	1	09	04	H8145_108_0	2	1		11	9d;	9d;17a;	2		2			1	0.00	0.00	2	
H8145	108	0	1	09	04	H8145_108_0	2	2		01	10a;11a;11b;11c;12;15;				1	20	20	2			2	
H8145	108	0	1	09	04	H8145_108_0	2	3		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;17b;18a;	14b;	2		1	35	35	2			2	
H8145	108	0	1	09	04	H8145_108_0	2	4		01	14a;				1	35	35	1	0.00	0.00	2	
H8145	108	0	1	09	04	H8145_108_0	2	5		10		13c;14c;	2		1	50	50	2			2	
H8145	108	0	1	09	04	H8145_108_0	2	6		10		13b;	1	25.00	1	50	50	2			2	
H8145	120	0	1	09	04	H8145_120_0	3	1		11	9d;	9d;17a;	2		2			1	0.00	0.00	2	
H8145	120	0	1	09	04	H8145_120_0	3	2		01	11a;12;15;				1	20	20	2			2	
H8145	120	0	1	09	04	H8145_120_0	3	3		01	10a;				1	20	20	1	265.00	265.00	2	
H8145	120	0	1	09	04	H8145_120_0	3	4		01	11b;11c;				1	20	40	2			2	
H8145	120	0	1	09	04	H8145_120_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;17b;18a;	14b;	2		1	40	40	2			2	
H8145	120	0	1	09	04	H8145_120_0	3	6		01	14a;				1	40	40	1	0.00	0.00	2	
H8145	120	0	1	09	04	H8145_120_0	3	7		10		13c;14c;	2		1	50	50	2			2	
H8145	121	0	1	09	04	H8145_121_0	6	1		11	9d;14a;14d;14e;	9d;14b;17a;	2		2			1	0.00	0.00	2	
H8145	121	0	1	09	04	H8145_121_0	6	2		01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;10a;11a;11b;11c;12;15;16b;17a;17b;18a;				1	20	20	2			2	
H8145	121	0	1	09	04	H8145_121_0	6	3		10		13c;14c;16a;	2		1	50	50	2			2	
H8145	121	0	1	09	04	H8145_121_0	6	4		10		13b;	1	15.00	1	50	50	2			2	
H8145	122	0	1	09	04	H8145_122_0	5	1		11	9d;	9d;17a;	2		2			1	0.00	0.00	2	
H8145	122	0	1	09	04	H8145_122_0	5	2		01	12;				1	20	20	2			2	
H8145	122	0	1	09	04	H8145_122_0	5	3		01	10a;				1	20	20	1	265.00	265.00	2	
H8145	122	0	1	09	04	H8145_122_0	5	4		01	15;				1	20	40	2			2	
H8145	122	0	1	09	04	H8145_122_0	5	5		10		18a;18b;	2		1	25	25	2			2	
H8145	122	0	1	09	04	H8145_122_0	5	6		01	11a;				1	30	30	2			2	
H8145	122	0	1	09	04	H8145_122_0	5	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;17b;18a;	14b;	2		1	40	40	2			2	
H8145	122	0	1	09	04	H8145_122_0	5	8		01	14a;				1	40	40	1	0.00	0.00	2	
H8145	122	0	1	09	04	H8145_122_0	5	9		10		13c;14c;16a;	2		1	50	50	2			2	
H8145	123	0	1	09	04	H8145_123_0	5	1		11	6;9d;14a;14d;14e;	9d;14b;17a;18a;	2		2			1	0.00	0.00	2	
H8145	123	0	1	09	04	H8145_123_0	5	10		01	5;7d;7f;16b;17a;18a;				2			1	50.00	50.00	2	
H8145	123	0	1	09	04	H8145_123_0	5	11		01	11a;11b;11c;15;				1	25	25	2			2	
H8145	123	0	1	09	04	H8145_123_0	5	12		01	8b2;				1	25	25	1	50.00	50.00	2	
H8145	123	0	1	09	04	H8145_123_0	5	13		10		13c;14c;16a;16b;	2		1	50	50	2			2	
H8145	123	0	1	09	04	H8145_123_0	5	14		10		13b;	1	20.00	1	50	50	2			2	
H8145	123	0	1	09	04	H8145_123_0	5	15		10		18b;	2		2			1	699.00	999.00	2	
H8145	123	0	1	09	04	H8145_123_0	5	2		01	8a1;8a2;				2			1	0.00	100.00	2	
H8145	123	0	1	09	04	H8145_123_0	5	3		01	7g;8b3;9c;				2			1	15.00	100.00	2	
H8145	123	0	1	09	04	H8145_123_0	5	4		01	7a;				2			1	15.00	15.00	2	
H8145	123	0	1	09	04	H8145_123_0	5	5		01	3-1;3-2;3-3;7b;7c;7e;7h;7i;17b;				2			1	20.00	40.00	2	
H8145	123	0	1	09	04	H8145_123_0	5	6		01	9b;				2			1	275.00	275.00	2	
H8145	123	0	1	09	04	H8145_123_0	5	7		01	8b1;9a;				2			1	50.00	325.00	2	
H8145	123	0	1	09	04	H8145_123_0	5	8		01	12;				1	20	20	2			2	
H8145	123	0	1	09	04	H8145_123_0	5	9		01	10a;				1	20	20	1	265.00	265.00	2	
H8145	125	0	1	09	04	H8145_125_0	4	1		11	9d;	9d;17a;	2		2			1	0.00	0.00	2	
H8145	125	0	1	09	04	H8145_125_0	4	2		01	12;				1	20	20	2			2	
H8145	125	0	1	09	04	H8145_125_0	4	3		01	10a;				1	20	20	1	265.00	265.00	2	
H8145	125	0	1	09	04	H8145_125_0	4	4		11	11a;	18a;18b;	2		1	25	25	2			2	
H8145	125	0	1	09	04	H8145_125_0	4	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	14b;	2		1	30	30	2			2	
H8145	125	0	1	09	04	H8145_125_0	4	6		01	14a;				1	30	30	1	0.00	0.00	2	
H8145	125	0	1	09	04	H8145_125_0	4	7		10		13c;14c;	2		1	50	50	2			2	
H8145	126	0	1	09	04	H8145_126_0	3	1		11	9d;	9d;17a;	2		2			1	0.00	0.00	2	
H8145	126	0	1	09	04	H8145_126_0	3	10		01	3-1;3-2;3-3;7c;7i;8b1;9c;				1	30	30	1	50.00	50.00	2	
H8145	126	0	1	09	04	H8145_126_0	3	11		10		13c;14c;	2		1	50	50	2			2	
H8145	126	0	1	09	04	H8145_126_0	3	12		10		13b;	1	10.00	1	50	50	2			2	
H8145	126	0	1	09	04	H8145_126_0	3	2		01	7a;				2			1	20.00	20.00	2	
H8145	126	0	1	09	04	H8145_126_0	3	3		01	7b;7d;7e;7f;7g;7h;16b;17a;18a;				2			1	50.00	50.00	2	
H8145	126	0	1	09	04	H8145_126_0	3	4		01	11a;11b;11c;12;				1	20	20	2			2	
H8145	126	0	1	09	04	H8145_126_0	3	5		01	10a;				1	20	20	1	265.00	265.00	2	
H8145	126	0	1	09	04	H8145_126_0	3	6		01	15;				1	20	30	2			2	
H8145	126	0	1	09	04	H8145_126_0	3	7		11	5;6;8b2;9a;9b;14d;14e;17b;	14b;	2		1	30	30	2			2	
H8145	126	0	1	09	04	H8145_126_0	3	8		01	14a;				1	30	30	1	0.00	0.00	2	
H8145	126	0	1	09	04	H8145_126_0	3	9		01	8a1;8a2;8b3;				1	30	30	1	20.00	50.00	2	
H8145	155	0	1	09	04	H8145_155_0	3	1		11	9d;	9d;	2		2			1	0.00	0.00	2	
H8145	155	0	1	09	04	H8145_155_0	3	2		01	11a;12;15;				1	20	20	2			2	
H8145	155	0	1	09	04	H8145_155_0	3	3		01	10a;				1	20	20	1	265.00	265.00	2	
H8145	155	0	1	09	04	H8145_155_0	3	4		01	11c;				1	20	30	2			2	
H8145	155	0	1	09	04	H8145_155_0	3	5		01	6;				1	25	25	2			2	
H8145	155	0	1	09	04	H8145_155_0	3	6		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;16b;17a;17b;18a;	14b;	2		1	30	30	2			2	
H8145	155	0	1	09	04	H8145_155_0	3	7		01	14a;				1	30	30	1	0.00	0.00	2	
H8145	155	0	1	09	04	H8145_155_0	3	8		10		13c;14c;	2		1	50	50	2			2	
H8211	001	0	1	04	01	H8211_001_0	4	1	Group 1	01	7a;7g;		2		2			1	40.00	70.00	2	
H8211	001	0	1	04	01	H8211_001_0	4	10	Group 10	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
H8211	001	0	1	04	01	H8211_001_0	4	11	Group 11	01	14a;		2		1	0	40	2			2	
H8211	001	0	1	04	01	H8211_001_0	4	12	Group 12	01	6;11a;		2		1	50	50	2			2	
H8211	001	0	1	04	01	H8211_001_0	4	13	Group 13	01	14e;		2		1	40	40	1	70.00	70.00	2	
H8211	001	0	1	04	01	H8211_001_0	4	14	Group 14	01	8a1;8a2;8b1;8b2;8b3;		2		1	40	40	1	10.00	21.00	2	
H8211	001	0	1	04	01	H8211_001_0	4	15	Group 15	10		13b;	1	50.00	2			1	0.00	0.00	2	
H8211	001	0	1	04	01	H8211_001_0	4	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	70.00	70.00	2	
H8211	001	0	1	04	01	H8211_001_0	4	3	Group 3	11	3-1;3-2;3-3;9a;9b;11b;11c;14d;15;16b;17b;	14b;	2		1	40	40	2			2	
H8211	001	0	1	04	01	H8211_001_0	4	4	Group 4	10		16a;	2		1	75	75	2			2	
H8211	001	0	1	04	01	H8211_001_0	4	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
H8211	001	0	1	04	01	H8211_001_0	4	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H8211	001	0	1	04	01	H8211_001_0	4	7	Group 7	01	10a;		2		2			1	250.00	250.00	2	
H8211	001	0	1	04	01	H8211_001_0	4	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H8211	001	0	1	04	01	H8211_001_0	4	9	Group 9	01	12;		2		1	20	20	2			2	
H8211	002	0	1	04	01	H8211_002_0	4	1	Group 1	01	7a;7g;		2		2			1	30.00	60.00	2	
H8211	002	0	1	04	01	H8211_002_0	4	10	Group 10	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
H8211	002	0	1	04	01	H8211_002_0	4	11	Group 11	01	14a;		2		1	0	40	2			2	
H8211	002	0	1	04	01	H8211_002_0	4	12	Group 12	01	6;11a;		2		1	50	50	2			2	
H8211	002	0	1	04	01	H8211_002_0	4	13	Group 13	01	14e;		2		1	40	40	1	60.00	60.00	2	
H8211	002	0	1	04	01	H8211_002_0	4	14	Group 14	01	8a1;8a2;8b1;8b2;8b3;		2		1	40	40	1	10.00	21.00	2	
H8211	002	0	1	04	01	H8211_002_0	4	15	Group 15	10		16a;	2		1	75	75	2			2	
H8211	002	0	1	04	01	H8211_002_0	4	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	60.00	60.00	2	
H8211	002	0	1	04	01	H8211_002_0	4	3	Group 3	11	3-1;3-2;3-3;9a;9b;11b;11c;14d;15;16b;17b;	14b;	2		1	40	40	2			2	
H8211	002	0	1	04	01	H8211_002_0	4	4	Group 4	10		13b;	1	50.00	2			1	0.00	0.00	2	
H8211	002	0	1	04	01	H8211_002_0	4	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
H8211	002	0	1	04	01	H8211_002_0	4	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H8211	002	0	1	04	01	H8211_002_0	4	7	Group 7	01	10a;		2		2			1	250.00	250.00	2	
H8211	002	0	1	04	01	H8211_002_0	4	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H8211	002	0	1	04	01	H8211_002_0	4	9	Group 9	01	12;		2		1	20	20	2			2	
H8211	003	0	1	04	01	H8211_003_0	4	1	Group 1	01	7a;7g;		2		2			1	40.00	70.00	2	
H8211	003	0	1	04	01	H8211_003_0	4	10	Group 10	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
H8211	003	0	1	04	01	H8211_003_0	4	11	Group 11	01	14a;		2		1	0	40	2			2	
H8211	003	0	1	04	01	H8211_003_0	4	12	Group 12	01	6;11a;		2		1	50	50	2			2	
H8211	003	0	1	04	01	H8211_003_0	4	13	Group 13	01	14e;		2		1	40	40	1	70.00	70.00	2	
H8211	003	0	1	04	01	H8211_003_0	4	14	Group 14	01	8a1;8a2;8b1;8b2;8b3;		2		1	40	40	1	10.00	21.00	2	
H8211	003	0	1	04	01	H8211_003_0	4	15	Group 15	10		13b;	1	50.00	2			1	0.00	0.00	2	
H8211	003	0	1	04	01	H8211_003_0	4	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	70.00	70.00	2	
H8211	003	0	1	04	01	H8211_003_0	4	3	Group 3	11	3-1;3-2;3-3;9a;9b;11b;11c;14d;15;16b;17b;	14b;	2		1	40	40	2			2	
H8211	003	0	1	04	01	H8211_003_0	4	4	Group 4	10		16a;	2		1	75	75	2			2	
H8211	003	0	1	04	01	H8211_003_0	4	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
H8211	003	0	1	04	01	H8211_003_0	4	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H8211	003	0	1	04	01	H8211_003_0	4	7	Group 7	01	10a;		2		2			1	250.00	250.00	2	
H8211	003	0	1	04	01	H8211_003_0	4	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H8211	003	0	1	04	01	H8211_003_0	4	9	Group 9	01	12;		2		1	20	20	2			2	
H8211	004	0	1	04	01	H8211_004_0	4	1	Group 1	01	7a;7g;		2		2			1	30.00	60.00	2	
H8211	004	0	1	04	01	H8211_004_0	4	10	Group 10	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
H8211	004	0	1	04	01	H8211_004_0	4	11	Group 11	01	14a;		2		1	0	40	2			2	
H8211	004	0	1	04	01	H8211_004_0	4	12	Group 12	01	6;11a;		2		1	50	50	2			2	
H8211	004	0	1	04	01	H8211_004_0	4	13	Group 13	01	14e;		2		1	40	40	1	60.00	60.00	2	
H8211	004	0	1	04	01	H8211_004_0	4	14	Group 14	01	8a1;8a2;8b1;8b2;8b3;		2		1	40	40	1	10.00	21.00	2	
H8211	004	0	1	04	01	H8211_004_0	4	15	Group 15	10		16a;	2		1	75	75	2			2	
H8211	004	0	1	04	01	H8211_004_0	4	2	Group 2	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	60.00	60.00	2	
H8211	004	0	1	04	01	H8211_004_0	4	3	Group 3	11	3-1;3-2;3-3;9a;9b;11b;11c;14d;15;16b;17b;	14b;	2		1	40	40	2			2	
H8211	004	0	1	04	01	H8211_004_0	4	4	Group 4	10		13b;	1	50.00	2			1	0.00	0.00	2	
H8211	004	0	1	04	01	H8211_004_0	4	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
H8211	004	0	1	04	01	H8211_004_0	4	6	Group 6	01	5;		2		2			1	75.00	75.00	2	
H8211	004	0	1	04	01	H8211_004_0	4	7	Group 7	01	10a;		2		2			1	250.00	250.00	2	
H8211	004	0	1	04	01	H8211_004_0	4	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H8211	004	0	1	04	01	H8211_004_0	4	9	Group 9	01	12;		2		1	20	20	2			2	
H8552	020	0	1	04	01	H8552_020_0	7	1	40% OON Coinsurance Group	11	3-1;3-2;3-3;5;6;9a;9b;9c;9d;14a;14d;14e;16b;17a;18a;	9d;14b;	2		1	40	40	2			2	
H8552	020	0	1	04	01	H8552_020_0	7	10	$0 Copay Group with $69 Max Benefit	10		17a;	2		2			1	0.00	0.00	2	
H8552	020	0	1	04	01	H8552_020_0	7	11	$0 - 50% OON Group	01	8a1;		2		1	50	50	1	0.00	0.00	2	
H8552	020	0	1	04	01	H8552_020_0	7	2	$30 OON Copayment Group	01	7a;7g;		2		2			1	30.00	30.00	2	
H8552	020	0	1	04	01	H8552_020_0	7	3	$50 Copayment Group	01	7b;7c;7d;7e;7f;7h;7i;		2		2			1	50.00	50.00	2	
H8552	020	0	1	04	01	H8552_020_0	7	4	20% Coinsurance Air $325 Copayment Group	01	10a;		2		1	20	20	1	325.00	325.00	2	
H8552	020	0	1	04	01	H8552_020_0	7	5	50% OON Coinsurance Group	01	8a2;8b1;8b2;8b3;		2		1	50	50	2			2	
H8552	020	0	1	04	01	H8552_020_0	7	6	$0 Copayment Group	01	17b;		2		2			1	0.00	0.00	2	
H8552	020	0	1	04	01	H8552_020_0	7	7	30% OON Group	01	11a;11b;11c;		2		1	30	30	2			2	
H8552	020	0	1	04	01	H8552_020_0	7	8	$0 Copayment Group	10		14c;	1	95.00	2			1	0.00	0.00	2	
H8552	020	0	1	04	01	H8552_020_0	7	9	20% Coinsurance Group	11	12;15;	16a;	2		1	20	20	2			2	
H8552	028	0	1	04	01	H8552_028_0	9	1	20% Coinsurance Group	11	3-1;3-2;3-3;5;7b;7c;7e;7f;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14e;15;16b;17a;17b;18a;	7f;9d;16a;18a;	2		1	20	20	2			2	
H8552	028	0	1	04	01	H8552_028_0	9	2	$0 Copayment Group	11	6;7a;7g;14d;	16b;17a;17b;	2		2			1	0.00	0.00	2	
H8552	028	0	1	04	01	H8552_028_0	9	3	50% Transportation	10		10b;	2		1	50	50	2			2	
H8552	028	0	1	04	01	H8552_028_0	9	4	SPC $0 - 20%	01	7d;		2		1	20	20	1	0.00	0.00	2	
H8552	028	0	1	04	01	H8552_028_0	9	5	$0 Copayment Group $95	10		14c;	1	95.00	2			1	0.00	0.00	2	
H8552	801	0	1	04	01	H8552_801_0	1	1		01	6;14a;		2		1	0	0	2			2	
H8552	801	0	1	04	01	H8552_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H8552	802	0	1	04	01	H8552_802_0	1	1		01	6;14a;		2		1	0	0	2			2	
H8552	802	0	1	04	01	H8552_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H8552	803	0	1	04	01	H8552_803_0	1	1		01	6;14a;		2		1	0	0	2			2	
H8552	803	0	1	04	01	H8552_803_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H8552	805	0	2	04	01	H8552_805_0	2	1		01	6;14a;		2		1	0	0	2			2	
H8552	805	0	2	04	01	H8552_805_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H8604	010	0	1	04	01	H8604_010_0	6	1	Group 1	11	3-1;3-2;3-3;5;6;8b1;8b2;8b3;9a;9b;9d;12;14a;14d;15;17b;	9d;14c;16a;	2		1	30	30	2			2	
H8604	010	0	1	04	01	H8604_010_0	6	2	Group 2	01	11a;11b;11c;		2		1	40	40	2			2	
H8604	010	0	1	04	01	H8604_010_0	6	3	Group 3	01	7a;		2		2			1	20.00	20.00	2	
H8604	010	0	1	04	01	H8604_010_0	6	4	Group 4	11	7b;7c;7d;7e;7f;7g;7h;7i;9c;16b;18a;	7f;17a;	2		2			1	45.00	45.00	2	
H8604	010	0	1	04	01	H8604_010_0	6	5	Group 5	01	10a;		2		1	20	20	1	200.00	200.00	2	
H8604	010	0	1	04	01	H8604_010_0	6	6	Group 6	10		17b;	2		1	20	20	2			2	
H8604	010	0	1	04	01	H8604_010_0	6	7	Group 7	01	8a1;8a2;14e;		2		1	30	30	2			2	
H8604	010	0	1	04	01	H8604_010_0	6	8	Group 8	01	17a;		2		2			1	20.00	45.00	2	
H8604	011	0	1	04	01	H8604_011_0	6	1	Group 1	11	3-1;3-2;3-3;5;6;8b1;8b2;8b3;9a;9b;9d;12;14a;14d;15;17b;	9d;14c;16a;	2		1	30	30	2			2	
H8604	011	0	1	04	01	H8604_011_0	6	2	Group 2	01	11a;11b;11c;		2		1	40	40	2			2	
H8604	011	0	1	04	01	H8604_011_0	6	3	Group 3	01	7a;		2		2			1	20.00	20.00	2	
H8604	011	0	1	04	01	H8604_011_0	6	4	Group 4	11	7b;7c;7d;7e;7f;7g;7h;7i;9c;16b;18a;	7f;17a;	2		2			1	45.00	45.00	2	
H8604	011	0	1	04	01	H8604_011_0	6	5	Group 5	01	10a;		2		1	20	20	1	200.00	200.00	2	
H8604	011	0	1	04	01	H8604_011_0	6	6	Group 6	10		17b;	2		1	20	20	2			2	
H8604	011	0	1	04	01	H8604_011_0	6	7	Group 7	01	8a1;8a2;14e;		2		1	30	30	2			2	
H8604	011	0	1	04	01	H8604_011_0	6	8	Group 8	01	17a;		2		2			1	20.00	45.00	2	
H8604	013	0	1	04	01	H8604_013_0	6	1	Group 1	11	3-1;3-2;3-3;5;6;8b1;8b2;8b3;9a;9b;9d;12;14a;14d;15;17b;	9d;14c;16a;	2		1	30	30	2			2	
H8604	013	0	1	04	01	H8604_013_0	6	2	Group 2	01	11a;11b;11c;		2		1	40	40	2			2	
H8604	013	0	1	04	01	H8604_013_0	6	3	Group 3	01	7a;		2		2			1	20.00	20.00	2	
H8604	013	0	1	04	01	H8604_013_0	6	4	Group 4	11	7b;7c;7d;7e;7f;7g;7h;7i;9c;16b;18a;	7f;17a;	2		2			1	45.00	45.00	2	
H8604	013	0	1	04	01	H8604_013_0	6	5	Group 5	01	10a;		2		1	20	20	1	200.00	200.00	2	
H8604	013	0	1	04	01	H8604_013_0	6	6	Group 6	10		17b;	2		1	20	20	2			2	
H8604	013	0	1	04	01	H8604_013_0	6	7	Group 7	01	8a1;8a2;14e;		2		1	30	30	2			2	
H8604	013	0	1	04	01	H8604_013_0	6	8	Group 8	01	17a;		2		2			1	20.00	45.00	2	
H8604	801	0	1	04	01	H8604_801_0	1	1		01	6;14a;		2		1	0	0	2			2	
H8604	801	0	1	04	01	H8604_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H8634	002	0	1	04	01	H8634_002_0	7	1	50% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	14b;	2		1	50	50	2			2	
H8634	002	0	1	04	01	H8634_002_0	7	2	$275 Copay	01	10a;		2		2			1	275.00	275.00	2	
H8634	002	0	1	04	01	H8634_002_0	7	3	20% Coinsurance	01	12;		2		1	20	20	2			2	
H8634	002	0	1	04	01	H8634_002_0	7	4	$0	10		14c;	2		2			2			2	
H8634	002	0	1	04	01	H8634_002_0	7	5	30% Coinsurance	01	11a;		2		1	30	30	2			2	
H8634	003	0	1	04	01	H8634_003_0	7	1	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	14b;	2		1	50	50	2			2	
H8634	003	0	1	04	01	H8634_003_0	7	2	$250	01	10a;		2		2			1	250.00	250.00	2	
H8634	003	0	1	04	01	H8634_003_0	7	3	20%	01	12;		2		1	20	20	2			2	
H8634	003	0	1	04	01	H8634_003_0	7	4	$0	10		14c;	2		2			1	0.00	0.00	2	
H8634	003	0	1	04	01	H8634_003_0	7	5	30% Coinsurance	01	11a;		2		1	30	30	2			2	
H8634	004	0	1	04	01	H8634_004_0	7	1	50% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	14b;	2		1	50	50	2			2	
H8634	004	0	1	04	01	H8634_004_0	7	2	$225	01	10a;		2		2			1	225.00	225.00	2	
H8634	004	0	1	04	01	H8634_004_0	7	3	20%	01	12;		2		1	20	20	2			2	
H8634	004	0	1	04	01	H8634_004_0	7	4	$0 Copay	10		14c;16a;	2		2			2			2	
H8634	004	0	1	04	01	H8634_004_0	7	5	30% coinsurance	01	11a;		2		1	30	30	2			2	
H8634	801	0	1	04	01	H8634_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
H8634	801	0	1	04	01	H8634_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H8634	803	0	1	04	01	H8634_803_0	3	1		01	6;14a;		2		1	0	0	2			2	
H8634	803	0	1	04	01	H8634_803_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H8634	805	0	1	04	01	H8634_805_0	3	1		01	6;14a;		2		1	0	0	2			2	
H8634	805	0	1	04	01	H8634_805_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H8634	807	0	1	04	01	H8634_807_0	2	1		01	6;14a;		2		1	0	0	2			2	
H8634	807	0	1	04	01	H8634_807_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H8634	809	0	1	04	01	H8634_809_0	2	1		01	6;14a;		2		1	0	0	2			2	
H8634	809	0	1	04	01	H8634_809_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H8634	811	0	1	04	01	H8634_811_0	2	1		01	6;14a;		2		1	0	0	2			2	
H8634	811	0	1	04	01	H8634_811_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H8634	813	0	1	04	01	H8634_813_0	3	1		01	6;14a;		2		1	0	0	2			2	
H8634	813	0	1	04	01	H8634_813_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H8634	815	0	1	04	01	H8634_815_0	3	1		01	6;14a;		2		1	0	0	2			2	
H8634	815	0	1	04	01	H8634_815_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H8634	817	0	1	04	01	H8634_817_0	3	1		01	6;14a;		2		1	0	0	2			2	
H8634	817	0	1	04	01	H8634_817_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H8768	001	0	1	04	01	H8768_001_0	5	1	Group 1	11	3-1;3-2;3-3;9a;9b;11b;11c;14d;15;16b;17b;	14b;	2		1	40	40	2			2	
H8768	001	0	1	04	01	H8768_001_0	5	10	Group 10	01	6;11a;		2		1	50	50	2			2	
H8768	001	0	1	04	01	H8768_001_0	5	11	Group 11	10		18b;	2		2			1	330.00	380.00	2	
H8768	001	0	1	04	01	H8768_001_0	5	12	Group 12	10		13b;	1	40.00	2			1	0.00	0.00	2	
H8768	001	0	1	04	01	H8768_001_0	5	13	Group 13	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	55.00	55.00	2	
H8768	001	0	1	04	01	H8768_001_0	5	14	Group 14	01	7a;		2		2			1	35.00	35.00	2	
H8768	001	0	1	04	01	H8768_001_0	5	15	Group 15	01	7g;		2		2			1	35.00	55.00	2	
H8768	001	0	1	04	01	H8768_001_0	5	2	Group 2	01	8a1;8a2;8b1;8b2;8b3;		2		1	40	40	1	2.00	10.00	2	
H8768	001	0	1	04	01	H8768_001_0	5	3	Group 3	01	14e;		2		1	40	40	1	55.00	55.00	2	
H8768	001	0	1	04	01	H8768_001_0	5	4	Group 4	01	5;		2		2			1	75.00	75.00	2	
H8768	001	0	1	04	01	H8768_001_0	5	5	Group 5	01	10a;		2		2			1	250.00	250.00	2	
H8768	001	0	1	04	01	H8768_001_0	5	6	Group 6	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H8768	001	0	1	04	01	H8768_001_0	5	7	Group 7	01	12;		2		1	20	20	2			2	
H8768	001	0	1	04	01	H8768_001_0	5	8	Group 8	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
H8768	001	0	1	04	01	H8768_001_0	5	9	Group 9	01	14a;		2		1	0	40	2			2	
H8768	002	0	1	04	01	H8768_002_0	5	1	Group 1	11	3-1;3-2;3-3;9a;9b;11b;11c;14d;15;16b;17b;	14b;	2		1	40	40	2			2	
H8768	002	0	1	04	01	H8768_002_0	5	10	Group 10	01	6;11a;		2		1	50	50	2			2	
H8768	002	0	1	04	01	H8768_002_0	5	11	Group 11	10		18b;	2		2			1	330.00	380.00	2	
H8768	002	0	1	04	01	H8768_002_0	5	12	Group 12	10		13b;	1	40.00	2			1	0.00	0.00	2	
H8768	002	0	1	04	01	H8768_002_0	5	13	Group 13	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	55.00	55.00	2	
H8768	002	0	1	04	01	H8768_002_0	5	14	Group 14	01	7a;		2		2			1	35.00	35.00	2	
H8768	002	0	1	04	01	H8768_002_0	5	15	Group 15	01	7g;		2		2			1	35.00	55.00	2	
H8768	002	0	1	04	01	H8768_002_0	5	2	Group 2	01	8a1;8a2;8b1;8b2;8b3;		2		1	40	40	1	2.00	14.00	2	
H8768	002	0	1	04	01	H8768_002_0	5	3	Group 3	01	14e;		2		1	40	40	1	55.00	55.00	2	
H8768	002	0	1	04	01	H8768_002_0	5	4	Group 4	01	5;		2		2			1	75.00	75.00	2	
H8768	002	0	1	04	01	H8768_002_0	5	5	Group 5	01	10a;		2		2			1	220.00	220.00	2	
H8768	002	0	1	04	01	H8768_002_0	5	6	Group 6	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H8768	002	0	1	04	01	H8768_002_0	5	7	Group 7	01	12;		2		1	20	20	2			2	
H8768	002	0	1	04	01	H8768_002_0	5	8	Group 8	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
H8768	002	0	1	04	01	H8768_002_0	5	9	Group 9	01	14a;		2		1	0	40	2			2	
H8768	003	0	1	04	01	H8768_003_0	5	1	Group 1	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;11b;11c;14d;15;16b;17b;	14b;17b;	2		1	40	40	2			2	
H8768	003	0	1	04	01	H8768_003_0	5	10	Group 10	01	6;11a;		2		1	50	50	2			2	
H8768	003	0	1	04	01	H8768_003_0	5	11	Group 11	10		18b;	2		2			1	330.00	380.00	2	
H8768	003	0	1	04	01	H8768_003_0	5	12	Group 12	10		13b;	1	50.00	2			1	0.00	0.00	2	
H8768	003	0	1	04	01	H8768_003_0	5	13	Group 13	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	50.00	50.00	2	
H8768	003	0	1	04	01	H8768_003_0	5	14	Group 14	01	7a;7g;		2		2			1	35.00	50.00	2	
H8768	003	0	1	04	01	H8768_003_0	5	15	Group 15	10		16a;	2		1	75	75	2			2	
H8768	003	0	1	04	01	H8768_003_0	5	2	Group 2	01	8b3;		2		2			1	21.00	21.00	2	
H8768	003	0	1	04	01	H8768_003_0	5	3	Group 3	01	14e;		2		1	40	40	1	50.00	50.00	2	
H8768	003	0	1	04	01	H8768_003_0	5	4	Group 4	01	5;		2		2			1	75.00	75.00	2	
H8768	003	0	1	04	01	H8768_003_0	5	5	Group 5	01	10a;		2		2			1	250.00	250.00	2	
H8768	003	0	1	04	01	H8768_003_0	5	6	Group 6	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H8768	003	0	1	04	01	H8768_003_0	5	7	Group 7	01	12;		2		1	20	20	2			2	
H8768	003	0	1	04	01	H8768_003_0	5	8	Group 8	11	8a2;9d;	9d;14c;	2		2			1	0.00	0.00	2	
H8768	003	0	1	04	01	H8768_003_0	5	9	Group 9	01	14a;		2		1	0	40	2			2	
H8768	004	0	1	04	01	H8768_004_0	5	1	Group 1	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;11b;11c;14d;15;16b;17b;	14b;17b;	2		1	40	40	2			2	
H8768	004	0	1	04	01	H8768_004_0	5	10	Group 10	01	6;11a;		2		1	50	50	2			2	
H8768	004	0	1	04	01	H8768_004_0	5	11	Group 11	10		18b;	2		2			1	330.00	380.00	2	
H8768	004	0	1	04	01	H8768_004_0	5	12	Group 12	10		13b;	1	50.00	2			1	0.00	0.00	2	
H8768	004	0	1	04	01	H8768_004_0	5	13	Group 13	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	50.00	50.00	2	
H8768	004	0	1	04	01	H8768_004_0	5	14	Group 14	01	7a;7g;		2		2			1	35.00	50.00	2	
H8768	004	0	1	04	01	H8768_004_0	5	15	Group 15	10		16a;	2		1	75	75	2			2	
H8768	004	0	1	04	01	H8768_004_0	5	2	Group 2	01	8b3;		2		2			1	21.00	21.00	2	
H8768	004	0	1	04	01	H8768_004_0	5	3	Group 3	01	14e;		2		1	40	40	1	50.00	50.00	2	
H8768	004	0	1	04	01	H8768_004_0	5	4	Group 4	01	5;		2		2			1	75.00	75.00	2	
H8768	004	0	1	04	01	H8768_004_0	5	5	Group 5	01	10a;		2		2			1	250.00	250.00	2	
H8768	004	0	1	04	01	H8768_004_0	5	6	Group 6	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
H8768	004	0	1	04	01	H8768_004_0	5	7	Group 7	01	12;		2		1	20	20	2			2	
H8768	004	0	1	04	01	H8768_004_0	5	8	Group 8	11	8a2;9d;	9d;14c;	2		2			1	0.00	0.00	2	
H8768	004	0	1	04	01	H8768_004_0	5	9	Group 9	01	14a;		2		1	0	40	2			2	
H8908	001	0	1	01	01	H8908_001_0	4	1														
H8908	002	0	1	01	01	H8908_002_0	4	1														
H8908	004	0	1	01	01	H8908_004_0	2	1														
H9312	001	0	1	04	01	H9312_001_0	6	1	outpatient	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	14c;	2		1	30	30	2			2	
H9312	001	0	1	04	01	H9312_001_0	6	2	Transportation	10		10b;	2		1	50	50	2			2	
H9312	001	0	1	04	01	H9312_001_0	6	3	Dental	10		16a;16b;	2		1	50	50	2			2	
H9312	001	0	1	04	01	H9312_001_0	6	4	OTC	10		13b;	1	37.76	2			2			2	
H9312	001	0	1	04	01	H9312_001_0	6	5	Eyewear	10		17b;	2		1	50	50	2			2	
H9312	001	0	1	04	01	H9312_001_0	6	6	Eye Exams	10		17a;	2		1	50	50	2			2	
H9312	002	0	1	04	01	H9312_002_0	6	1	outpatient	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	14c;	2		1	30	30	2			2	
H9312	002	0	1	04	01	H9312_002_0	6	2	Transportation	10		10b;	2		1	50	50	2			2	
H9312	002	0	1	04	01	H9312_002_0	6	3	Dental	10		16a;16b;	2		1	50	50	2			2	
H9312	002	0	1	04	01	H9312_002_0	6	4	OTC	10		13b;	1	37.76	2			2			2	
H9312	002	0	1	04	01	H9312_002_0	6	5	Eyewear	10		17b;	2		1	50	50	2			2	
H9312	002	0	1	04	01	H9312_002_0	6	6	Eye Exams	10		17a;	2		1	50	50	2			2	
H9408	001	0	1	04	01	H9408_001_0	7	1	40% coinsurance	11	5;6;7e;7h;8b1;8b2;8b3;9a;9b;11a;11b;11c;12;14a;14d;14e;15;17a;17b;	14b;17b;18b;	2		1	40	40	2			2	
H9408	001	0	1	04	01	H9408_001_0	7	2	$45 OON Copay	01	7b;		2		2			1	45.00	45.00	2	
H9408	001	0	1	04	01	H9408_001_0	7	3	20% Coinsurance	11	8a1;8a2;9d;	9d;	2		1	20	20	2			2	
H9408	001	0	1	04	01	H9408_001_0	7	4	$35 Copay	01	7a;		2		2			1	35.00	35.00	2	
H9408	001	0	1	04	01	H9408_001_0	7	5	$75 Copay	11	3-1;3-2;3-3;7c;7d;7f;7g;7i;9c;18a;	18a;	2		2			1	75.00	75.00	2	
H9408	001	0	1	04	01	H9408_001_0	7	6	OON Ambulance	01	10a;		2		2			1	225.00	225.00	2	
H9408	001	0	1	04	01	H9408_001_0	7	7	$70 copayment	01	16b;		2		2			1	70.00	70.00	2	
H9408	001	0	1	04	01	H9408_001_0	7	8	50% coinsurance	10		17a;	2		1	50	50	2			2	
H9408	002	0	1	04	01	H9408_002_0	6	1	$20 Copay	10		16a;	2		2			1	20.00	20.00	2	
H9408	002	0	1	04	01	H9408_002_0	6	2	OON Ambulance	01	10a;		2		2			1	150.00	150.00	2	
H9408	002	0	1	04	01	H9408_002_0	6	3	Fitness Benefit	10		14c;	1	90.00	2			2			2	
H9408	002	0	1	04	01	H9408_002_0	6	4	30% coinsurance group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11c;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;17b;18a;18b;	2		1	30	30	2			2	
H9408	002	0	1	04	01	H9408_002_0	6	5	Transportation Coverage	10		10b;	1	360.00	2			2			2	
H9408	002	0	1	04	01	H9408_002_0	6	6	35% Coinsurance	01	11a;11b;12;		2		1	35	35	2			2	
H9408	801	0	1	04	01	H9408_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
H9408	801	0	1	04	01	H9408_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H9408	802	0	1	04	01	H9408_802_0	2	1		01	6;14a;		2		1	0	0	2			2	
H9408	802	0	1	04	01	H9408_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H9408	803	0	1	04	01	H9408_803_0	2	1		01	6;14a;		2		1	0	0	2			2	
H9408	803	0	1	04	01	H9408_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H9408	804	0	1	04	01	H9408_804_0	2	1		01	6;14a;		2		1	0	0	2			2	
H9408	804	0	1	04	01	H9408_804_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H9412	803	0	1	04	01	H9412_803_0	3	1	$0	01	14a;		2		2			2			2	
H9412	803	0	1	04	01	H9412_803_0	3	2	Medicare Cost Sharing All Other Benefits	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H9572	001	1	1	04	01	H9572_001_1	6	1	Global Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;16b;17a;17b;	7b;	2		1	40	40	2			2	
H9572	001	1	1	04	01	H9572_001_1	6	10	Part B Drugs	01	15;		2		1	0	40	2			2	
H9572	001	1	1	04	01	H9572_001_1	6	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2			2	
H9572	001	1	1	04	01	H9572_001_1	6	3	Hearing Exams	11	18a;	18a;	2		1	50	50	2			2	
H9572	001	1	1	04	01	H9572_001_1	6	4	Preventive Dental	10		16a;	2		1	50	50	2			2	
H9572	001	1	1	04	01	H9572_001_1	6	5	Zero Coinsurance/Copay Group	11	9d;11c;14a;14e;	9d;14b;	2		2			2			2	
H9572	001	1	1	04	01	H9572_001_1	6	6	Supplemental Vision	10		17a;	2		1	40	40	1	10.00	10.00	2	
H9572	001	1	1	04	01	H9572_001_1	6	7	Hearing Aids	10		18b;	2		2			2			2	
H9572	001	1	1	04	01	H9572_001_1	6	8	Supplemental Vision - Eyewear	10		17b;	2		2			2			2	
H9572	001	1	1	04	01	H9572_001_1	6	9	Ambulance Services	01	10a;		2		1	40	40	1	200.00	200.00	2	
H9572	001	2	1	04	01	H9572_001_2	6	1	Global Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;16b;17a;17b;	7b;	2		1	40	40	2			2	
H9572	001	2	1	04	01	H9572_001_2	6	10	Part B Drugs	01	15;		2		1	0	40	2			2	
H9572	001	2	1	04	01	H9572_001_2	6	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2			2	
H9572	001	2	1	04	01	H9572_001_2	6	3	Hearing Exams	11	18a;	18a;	2		1	50	50	2			2	
H9572	001	2	1	04	01	H9572_001_2	6	4	Preventive Dental	10		16a;	2		1	50	50	2			2	
H9572	001	2	1	04	01	H9572_001_2	6	5	Zero Coinsurance/Copay Group	11	9d;11c;14a;14e;	9d;14b;	2		2			2			2	
H9572	001	2	1	04	01	H9572_001_2	6	6	Supplemental Vision	10		17a;	2		1	40	40	1	10.00	10.00	2	
H9572	001	2	1	04	01	H9572_001_2	6	7	Hearing Aids	10		18b;	2		2			2			2	
H9572	001	2	1	04	01	H9572_001_2	6	8	Supplemental Vision - Eyewear	10		17b;	2		2			2			2	
H9572	001	2	1	04	01	H9572_001_2	6	9	Ambulance Services	01	10a;		2		1	40	40	1	200.00	200.00	2	
H9572	001	3	1	04	01	H9572_001_3	6	1	Global Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;16b;17a;17b;	7b;	2		1	40	40	2			2	
H9572	001	3	1	04	01	H9572_001_3	6	10	Part B Drugs	01	15;		2		1	0	40	2			2	
H9572	001	3	1	04	01	H9572_001_3	6	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2			2	
H9572	001	3	1	04	01	H9572_001_3	6	3	Hearing Exams	11	18a;	18a;	2		1	50	50	2			2	
H9572	001	3	1	04	01	H9572_001_3	6	4	Preventive Dental	10		16a;	2		1	50	50	2			2	
H9572	001	3	1	04	01	H9572_001_3	6	5	Zero Coinsurance/Copay Group	11	9d;11c;14a;14e;	9d;14b;	2		2			2			2	
H9572	001	3	1	04	01	H9572_001_3	6	6	Supplemental Vision	10		17a;	2		1	40	40	1	10.00	10.00	2	
H9572	001	3	1	04	01	H9572_001_3	6	7	Hearing Aids	10		18b;	2		2			2			2	
H9572	001	3	1	04	01	H9572_001_3	6	8	Supplemental Vision - Eyewear	10		17b;	2		2			2			2	
H9572	001	3	1	04	01	H9572_001_3	6	9	Ambulance Services	01	10a;		2		1	40	40	1	200.00	200.00	2	
H9572	001	4	1	04	01	H9572_001_4	6	1	Global Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;16b;17a;17b;	7b;	2		1	40	40	2			2	
H9572	001	4	1	04	01	H9572_001_4	6	10	Part B Drugs	01	15;		2		1	0	40	2			2	
H9572	001	4	1	04	01	H9572_001_4	6	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2			2	
H9572	001	4	1	04	01	H9572_001_4	6	3	Hearing Exams	11	18a;	18a;	2		1	50	50	2			2	
H9572	001	4	1	04	01	H9572_001_4	6	4	Preventive Dental	10		16a;	2		1	50	50	2			2	
H9572	001	4	1	04	01	H9572_001_4	6	5	Zero Coinsurance/Copay Group	11	9d;11c;14a;14e;	9d;14b;	2		2			2			2	
H9572	001	4	1	04	01	H9572_001_4	6	6	Supplemental Vision	10		17a;	2		1	40	40	1	10.00	10.00	2	
H9572	001	4	1	04	01	H9572_001_4	6	7	Hearing Aids	10		18b;	2		2			2			2	
H9572	001	4	1	04	01	H9572_001_4	6	8	Supplemental Vision - Eyewear	10		17b;	2		2			2			2	
H9572	001	4	1	04	01	H9572_001_4	6	9	Ambulance Services	01	10a;		2		1	40	40	1	200.00	200.00	2	
H9572	001	6	1	04	01	H9572_001_6	6	1	Global Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;16b;17a;17b;	7b;	2		1	40	40	2			2	
H9572	001	6	1	04	01	H9572_001_6	6	10	Part B Drugs	01	15;		2		1	0	40	2			2	
H9572	001	6	1	04	01	H9572_001_6	6	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2			2	
H9572	001	6	1	04	01	H9572_001_6	6	3	Hearing Exams	11	18a;	18a;	2		1	50	50	2			2	
H9572	001	6	1	04	01	H9572_001_6	6	4	Preventive Dental	10		16a;	2		1	50	50	2			2	
H9572	001	6	1	04	01	H9572_001_6	6	5	Zero Coinsurance/Copay Group	11	9d;11c;14a;14e;	9d;14b;	2		2			2			2	
H9572	001	6	1	04	01	H9572_001_6	6	6	Supplemental Vision	10		17a;	2		1	40	40	1	10.00	10.00	2	
H9572	001	6	1	04	01	H9572_001_6	6	7	Hearing Aids	10		18b;	2		2			2			2	
H9572	001	6	1	04	01	H9572_001_6	6	8	Supplemental Vision - Eyewear	10		17b;	2		2			2			2	
H9572	001	6	1	04	01	H9572_001_6	6	9	Ambulance Services	01	10a;		2		1	40	40	1	200.00	200.00	2	
H9572	002	1	1	04	01	H9572_002_1	7	1	Global Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;16b;17a;17b;	7b;	2		1	40	40	2			2	
H9572	002	1	1	04	01	H9572_002_1	7	10	Part B Drugs	01	15;		2		1	0	40	2			2	
H9572	002	1	1	04	01	H9572_002_1	7	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2			2	
H9572	002	1	1	04	01	H9572_002_1	7	3	Hearing Exams	11	18a;	18a;	2		1	50	50	2			2	
H9572	002	1	1	04	01	H9572_002_1	7	4	Preventive Dental	10		16a;	2		1	50	50	2			2	
H9572	002	1	1	04	01	H9572_002_1	7	5	Zero Coinsurance/Copay Group	11	9d;11c;14a;14e;	9d;14b;	2		2			2			2	
H9572	002	1	1	04	01	H9572_002_1	7	6	Supplemental Vision	10		17a;	2		1	40	40	1	10.00	10.00	2	
H9572	002	1	1	04	01	H9572_002_1	7	7	Hearing Aids	10		18b;	2		2			2			2	
H9572	002	1	1	04	01	H9572_002_1	7	8	Supplemental Vision - Eyewear	10		17b;	2		2			2			2	
H9572	002	1	1	04	01	H9572_002_1	7	9	Ambulance Services	01	10a;		2		1	40	40	1	200.00	200.00	2	
H9572	002	2	1	04	01	H9572_002_2	7	1	Global Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;16b;17a;17b;	7b;	2		1	40	40	2			2	
H9572	002	2	1	04	01	H9572_002_2	7	10	Part B Drugs	01	15;		2		1	0	40	2			2	
H9572	002	2	1	04	01	H9572_002_2	7	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2			2	
H9572	002	2	1	04	01	H9572_002_2	7	3	Hearing Exams	11	18a;	18a;	2		1	50	50	2			2	
H9572	002	2	1	04	01	H9572_002_2	7	4	Preventive Dental	10		16a;	2		1	50	50	2			2	
H9572	002	2	1	04	01	H9572_002_2	7	5	Zero Coinsurance/Copay Group	11	9d;11c;14a;14e;	9d;14b;	2		2			2			2	
H9572	002	2	1	04	01	H9572_002_2	7	6	Supplemental Vision	10		17a;	2		1	40	40	1	10.00	10.00	2	
H9572	002	2	1	04	01	H9572_002_2	7	7	Hearing Aids	10		18b;	2		2			2			2	
H9572	002	2	1	04	01	H9572_002_2	7	8	Supplemental Vision - Eyewear	10		17b;	2		2			2			2	
H9572	002	2	1	04	01	H9572_002_2	7	9	Ambulance Services	01	10a;		2		1	40	40	1	200.00	200.00	2	
H9572	002	3	1	04	01	H9572_002_3	7	1	Global Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;16b;17a;17b;	7b;	2		1	40	40	2			2	
H9572	002	3	1	04	01	H9572_002_3	7	10	Part B Drugs	01	15;		2		1	0	40	2			2	
H9572	002	3	1	04	01	H9572_002_3	7	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2			2	
H9572	002	3	1	04	01	H9572_002_3	7	3	Hearing Exams	11	18a;	18a;	2		1	50	50	2			2	
H9572	002	3	1	04	01	H9572_002_3	7	4	Preventive Dental	10		16a;	2		1	50	50	2			2	
H9572	002	3	1	04	01	H9572_002_3	7	5	Zero Coinsurance/Copay Group	11	9d;11c;14a;14e;	9d;14b;	2		2			2			2	
H9572	002	3	1	04	01	H9572_002_3	7	6	Supplemental Vision	10		17a;	2		1	40	40	1	10.00	10.00	2	
H9572	002	3	1	04	01	H9572_002_3	7	7	Hearing Aids	10		18b;	2		2			2			2	
H9572	002	3	1	04	01	H9572_002_3	7	8	Supplemental Vision - Eyewear	10		17b;	2		2			2			2	
H9572	002	3	1	04	01	H9572_002_3	7	9	Ambulance Services	01	10a;		2		1	40	40	1	200.00	200.00	2	
H9572	002	4	1	04	01	H9572_002_4	7	1	Global Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;16b;17a;17b;	7b;	2		1	40	40	2			2	
H9572	002	4	1	04	01	H9572_002_4	7	10	Part B Drugs	01	15;		2		1	0	40	2			2	
H9572	002	4	1	04	01	H9572_002_4	7	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2			2	
H9572	002	4	1	04	01	H9572_002_4	7	3	Hearing Exams	11	18a;	18a;	2		1	50	50	2			2	
H9572	002	4	1	04	01	H9572_002_4	7	4	Preventive Dental	10		16a;	2		1	50	50	2			2	
H9572	002	4	1	04	01	H9572_002_4	7	5	Zero Coinsurance/Copay Group	11	9d;11c;14a;14e;	9d;14b;	2		2			2			2	
H9572	002	4	1	04	01	H9572_002_4	7	6	Supplemental Vision	10		17a;	2		1	40	40	1	10.00	10.00	2	
H9572	002	4	1	04	01	H9572_002_4	7	7	Hearing Aids	10		18b;	2		2			2			2	
H9572	002	4	1	04	01	H9572_002_4	7	8	Supplemental Vision - Eyewear	10		17b;	2		2			2			2	
H9572	002	4	1	04	01	H9572_002_4	7	9	Ambulance Services	01	10a;		2		1	40	40	1	200.00	200.00	2	
H9572	002	6	1	04	01	H9572_002_6	7	1	Global Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;16b;17a;17b;	7b;	2		1	40	40	2			2	
H9572	002	6	1	04	01	H9572_002_6	7	10	Part B Drugs	01	15;		2		1	0	40	2			2	
H9572	002	6	1	04	01	H9572_002_6	7	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2			2	
H9572	002	6	1	04	01	H9572_002_6	7	3	Hearing Exams	11	18a;	18a;	2		1	50	50	2			2	
H9572	002	6	1	04	01	H9572_002_6	7	4	Preventive Dental	10		16a;	2		1	50	50	2			2	
H9572	002	6	1	04	01	H9572_002_6	7	5	Zero Coinsurance/Copay Group	11	9d;11c;14a;14e;	9d;14b;	2		2			2			2	
H9572	002	6	1	04	01	H9572_002_6	7	6	Supplemental Vision	10		17a;	2		1	40	40	1	10.00	10.00	2	
H9572	002	6	1	04	01	H9572_002_6	7	7	Hearing Aids	10		18b;	2		2			2			2	
H9572	002	6	1	04	01	H9572_002_6	7	8	Supplemental Vision - Eyewear	10		17b;	2		2			2			2	
H9572	002	6	1	04	01	H9572_002_6	7	9	Ambulance Services	01	10a;		2		1	40	40	1	200.00	200.00	2	
H9572	003	1	1	04	01	H9572_003_1	6	1	Global Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;16b;17a;17b;	7b;	2		1	30	30	2			2	
H9572	003	1	1	04	01	H9572_003_1	6	10	Part B Drugs	01	15;		2		1	0	30	2			2	
H9572	003	1	1	04	01	H9572_003_1	6	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2			2	
H9572	003	1	1	04	01	H9572_003_1	6	3	Hearing Exams	11	18a;	18a;	2		1	50	50	2			2	
H9572	003	1	1	04	01	H9572_003_1	6	4	Preventive Dental	10		16a;	2		1	50	50	2			2	
H9572	003	1	1	04	01	H9572_003_1	6	5	Zero Coinsurance/Copay Group	11	9d;11c;14a;14e;	9d;14b;	2		2			2			2	
H9572	003	1	1	04	01	H9572_003_1	6	6	Supplemental Vision	10		17a;	2		1	30	30	1	10.00	10.00	2	
H9572	003	1	1	04	01	H9572_003_1	6	7	Hearing Aids	10		18b;	2		2			2			2	
H9572	003	1	1	04	01	H9572_003_1	6	8	Supplemental Vision - Eyewear	10		17b;	2		2			2			2	
H9572	003	1	1	04	01	H9572_003_1	6	9	Ambulance Services	01	10a;		2		1	30	30	1	200.00	200.00	2	
H9572	003	2	1	04	01	H9572_003_2	6	1	Global Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;16b;17a;17b;	7b;	2		1	30	30	2			2	
H9572	003	2	1	04	01	H9572_003_2	6	10	Part B Drugs	01	15;		2		1	0	30	2			2	
H9572	003	2	1	04	01	H9572_003_2	6	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2			2	
H9572	003	2	1	04	01	H9572_003_2	6	3	Hearing Exams	11	18a;	18a;	2		1	50	50	2			2	
H9572	003	2	1	04	01	H9572_003_2	6	4	Preventive Dental	10		16a;	2		1	50	50	2			2	
H9572	003	2	1	04	01	H9572_003_2	6	5	Zero Coinsurance/Copay Group	11	9d;11c;14a;14e;	9d;14b;	2		2			2			2	
H9572	003	2	1	04	01	H9572_003_2	6	6	Supplemental Vision	10		17a;	2		1	30	30	1	10.00	10.00	2	
H9572	003	2	1	04	01	H9572_003_2	6	7	Hearing Aids	10		18b;	2		2			2			2	
H9572	003	2	1	04	01	H9572_003_2	6	8	Supplemental Vision - Eyewear	10		17b;	2		2			2			2	
H9572	003	2	1	04	01	H9572_003_2	6	9	Ambulance Services	01	10a;		2		1	30	30	1	200.00	200.00	2	
H9572	003	3	1	04	01	H9572_003_3	6	1	Global Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;16b;17a;17b;	7b;	2		1	30	30	2			2	
H9572	003	3	1	04	01	H9572_003_3	6	10	Part B Drugs	01	15;		2		1	0	30	2			2	
H9572	003	3	1	04	01	H9572_003_3	6	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2			2	
H9572	003	3	1	04	01	H9572_003_3	6	3	Hearing Exams	11	18a;	18a;	2		1	50	50	2			2	
H9572	003	3	1	04	01	H9572_003_3	6	4	Preventive Dental	10		16a;	2		1	50	50	2			2	
H9572	003	3	1	04	01	H9572_003_3	6	5	Zero Coinsurance/Copay Group	11	9d;11c;14a;14e;	9d;14b;	2		2			2			2	
H9572	003	3	1	04	01	H9572_003_3	6	6	Supplemental Vision	10		17a;	2		1	30	30	1	10.00	10.00	2	
H9572	003	3	1	04	01	H9572_003_3	6	7	Hearing Aids	10		18b;	2		2			2			2	
H9572	003	3	1	04	01	H9572_003_3	6	8	Supplemental Vision - Eyewear	10		17b;	2		2			2			2	
H9572	003	3	1	04	01	H9572_003_3	6	9	Ambulance Services	01	10a;		2		1	30	30	1	200.00	200.00	2	
H9572	003	4	1	04	01	H9572_003_4	6	1	Global Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;16b;17a;17b;	7b;	2		1	30	30	2			2	
H9572	003	4	1	04	01	H9572_003_4	6	10	Part B Drugs	01	15;		2		1	0	30	2			2	
H9572	003	4	1	04	01	H9572_003_4	6	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2			2	
H9572	003	4	1	04	01	H9572_003_4	6	3	Hearing Exams	11	18a;	18a;	2		1	50	50	2			2	
H9572	003	4	1	04	01	H9572_003_4	6	4	Preventive Dental	10		16a;	2		1	50	50	2			2	
H9572	003	4	1	04	01	H9572_003_4	6	5	Zero Coinsurance/Copay Group	11	9d;11c;14a;14e;	9d;14b;	2		2			2			2	
H9572	003	4	1	04	01	H9572_003_4	6	6	Supplemental Vision	10		17a;	2		1	30	30	1	10.00	10.00	2	
H9572	003	4	1	04	01	H9572_003_4	6	7	Hearing Aids	10		18b;	2		2			2			2	
H9572	003	4	1	04	01	H9572_003_4	6	8	Supplemental Vision - Eyewear	10		17b;	2		2			2			2	
H9572	003	4	1	04	01	H9572_003_4	6	9	Ambulance Services	01	10a;		2		1	30	30	1	200.00	200.00	2	
H9572	003	6	1	04	01	H9572_003_6	6	1	Global Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;16b;17a;17b;	7b;	2		1	30	30	2			2	
H9572	003	6	1	04	01	H9572_003_6	6	10	Part B Drugs	01	15;		2		1	0	30	2			2	
H9572	003	6	1	04	01	H9572_003_6	6	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2			2	
H9572	003	6	1	04	01	H9572_003_6	6	3	Hearing Exams	11	18a;	18a;	2		1	50	50	2			2	
H9572	003	6	1	04	01	H9572_003_6	6	4	Preventive Dental	10		16a;	2		1	50	50	2			2	
H9572	003	6	1	04	01	H9572_003_6	6	5	Zero Coinsurance/Copay Group	11	9d;11c;14a;14e;	9d;14b;	2		2			2			2	
H9572	003	6	1	04	01	H9572_003_6	6	6	Supplemental Vision	10		17a;	2		1	30	30	1	10.00	10.00	2	
H9572	003	6	1	04	01	H9572_003_6	6	7	Hearing Aids	10		18b;	2		2			2			2	
H9572	003	6	1	04	01	H9572_003_6	6	8	Supplemental Vision - Eyewear	10		17b;	2		2			2			2	
H9572	003	6	1	04	01	H9572_003_6	6	9	Ambulance Services	01	10a;		2		1	30	30	1	200.00	200.00	2	
H9572	004	1	1	04	01	H9572_004_1	6	1	Global Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;16b;17a;17b;	7b;	2		1	50	50	2			2	
H9572	004	1	1	04	01	H9572_004_1	6	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2			2	
H9572	004	1	1	04	01	H9572_004_1	6	3	Hearing Exams	01	18a;		2		1	50	50	2			2	
H9572	004	1	1	04	01	H9572_004_1	6	4	Zero Coinsurance/Copay Group	11	9d;11c;14a;14e;	9d;14b;	2		2			2			2	
H9572	004	1	1	04	01	H9572_004_1	6	5	Supplemental Vision	10		17a;	2		1	50	50	1	20.00	20.00	2	
H9572	004	1	1	04	01	H9572_004_1	6	6	Ambulance Services	01	10a;		2		1	50	50	1	200.00	200.00	2	
H9572	004	1	1	04	01	H9572_004_1	6	7	Part B Drugs	01	15;		2		1	0	50	2			2	
H9572	004	2	1	04	01	H9572_004_2	6	1	Global Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;16b;17a;17b;	7b;	2		1	50	50	2			2	
H9572	004	2	1	04	01	H9572_004_2	6	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2			2	
H9572	004	2	1	04	01	H9572_004_2	6	3	Hearing Exams	01	18a;		2		1	50	50	2			2	
H9572	004	2	1	04	01	H9572_004_2	6	4	Zero Coinsurance/Copay Group	11	9d;11c;14a;14e;	9d;14b;	2		2			2			2	
H9572	004	2	1	04	01	H9572_004_2	6	5	Supplemental Vision	10		17a;	2		1	50	50	1	20.00	20.00	2	
H9572	004	2	1	04	01	H9572_004_2	6	6	Ambulance Services	01	10a;		2		1	50	50	1	200.00	200.00	2	
H9572	004	2	1	04	01	H9572_004_2	6	7	Part B Drugs	01	15;		2		1	0	50	2			2	
H9572	004	3	1	04	01	H9572_004_3	6	1	Global Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;16b;17a;17b;	7b;	2		1	50	50	2			2	
H9572	004	3	1	04	01	H9572_004_3	6	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2			2	
H9572	004	3	1	04	01	H9572_004_3	6	3	Hearing Exams	01	18a;		2		1	50	50	2			2	
H9572	004	3	1	04	01	H9572_004_3	6	4	Zero Coinsurance/Copay Group	11	9d;11c;14a;14e;	9d;14b;	2		2			2			2	
H9572	004	3	1	04	01	H9572_004_3	6	5	Supplemental Vision	10		17a;	2		1	50	50	1	20.00	20.00	2	
H9572	004	3	1	04	01	H9572_004_3	6	6	Ambulance Services	01	10a;		2		1	50	50	1	200.00	200.00	2	
H9572	004	3	1	04	01	H9572_004_3	6	7	Part B Drugs	01	15;		2		1	0	50	2			2	
H9572	004	4	1	04	01	H9572_004_4	6	1	Global Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;16b;17a;17b;	7b;	2		1	50	50	2			2	
H9572	004	4	1	04	01	H9572_004_4	6	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2			2	
H9572	004	4	1	04	01	H9572_004_4	6	3	Hearing Exams	01	18a;		2		1	50	50	2			2	
H9572	004	4	1	04	01	H9572_004_4	6	4	Zero Coinsurance/Copay Group	11	9d;11c;14a;14e;	9d;14b;	2		2			2			2	
H9572	004	4	1	04	01	H9572_004_4	6	5	Supplemental Vision	10		17a;	2		1	50	50	1	20.00	20.00	2	
H9572	004	4	1	04	01	H9572_004_4	6	6	Ambulance Services	01	10a;		2		1	50	50	1	200.00	200.00	2	
H9572	004	4	1	04	01	H9572_004_4	6	7	Part B Drugs	01	15;		2		1	0	50	2			2	
H9572	004	6	1	04	01	H9572_004_6	6	1	Global Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;16b;17a;17b;	7b;	2		1	50	50	2			2	
H9572	004	6	1	04	01	H9572_004_6	6	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2			2	
H9572	004	6	1	04	01	H9572_004_6	6	3	Hearing Exams	01	18a;		2		1	50	50	2			2	
H9572	004	6	1	04	01	H9572_004_6	6	4	Zero Coinsurance/Copay Group	11	9d;11c;14a;14e;	9d;14b;	2		2			2			2	
H9572	004	6	1	04	01	H9572_004_6	6	5	Supplemental Vision	10		17a;	2		1	50	50	1	20.00	20.00	2	
H9572	004	6	1	04	01	H9572_004_6	6	6	Ambulance Services	01	10a;		2		1	50	50	1	200.00	200.00	2	
H9572	004	6	1	04	01	H9572_004_6	6	7	Part B Drugs	01	15;		2		1	0	50	2			2	
H9572	801	0	1	04	01	H9572_801_0	4	1		01	6;14a;		2		1	0	0	2			2	
H9572	801	0	1	04	01	H9572_801_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H9572	802	0	1	04	01	H9572_802_0	4	1		01	6;14a;		2		1	0	0	2			2	
H9572	802	0	1	04	01	H9572_802_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H9572	803	0	1	04	01	H9572_803_0	4	1		01	6;14a;		2		1	0	0	2			2	
H9572	803	0	1	04	01	H9572_803_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H9572	804	0	1	04	01	H9572_804_0	4	1		01	6;14a;		2		1	0	0	2			2	
H9572	804	0	1	04	01	H9572_804_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H9572	805	0	1	04	01	H9572_805_0	4	1		01	6;14a;		2		1	0	0	2			2	
H9572	805	0	1	04	01	H9572_805_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H9589	001	0	1	04	01	H9589_001_0	9	1	Ambulance	01	10a;		2		2			1	225.00	225.00	2	
H9589	001	0	1	04	01	H9589_001_0	9	2	Preventive Services	01	14a;		2		2			2			2	
H9589	001	0	1	04	01	H9589_001_0	9	3	All Others	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;	7f;	2		1	40	40	2			2	
H9589	001	0	1	04	01	H9589_001_0	9	4	Supplemental Benefits	10		7b;9d;14c;16a;17a;18a;	2		1	50	50	2			2	
H9589	001	0	1	04	01	H9589_001_0	9	5	OTC	10		13b;	1	20.00	1	50	50	2			2	
H9589	001	0	1	04	01	H9589_001_0	9	6		10		17b;	2		1	50	50	2			2	
H9589	001	0	1	04	01	H9589_001_0	9	7	Eyewear	10		18b;	1	750.00	1	50	50	2			2	
H9589	003	0	1	04	01	H9589_003_0	9	1	Ambulance	01	10a;		2		2			1	225.00	225.00	2	
H9589	003	0	1	04	01	H9589_003_0	9	2	Preventive Services	01	14a;		2		2			2			2	
H9589	003	0	1	04	01	H9589_003_0	9	3	All Others	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	40	40	2			2	
H9589	003	0	1	04	01	H9589_003_0	9	4	Supplemental Benefits	10		7b;9d;14c;16a;17a;18a;	2		1	50	50	2			2	
H9589	003	0	1	04	01	H9589_003_0	9	5	OTC	10		13b;	1	20.00	1	50	50	2			2	
H9589	003	0	1	04	01	H9589_003_0	9	6		10		17b;	2		1	50	50	2			2	
H9589	003	0	1	04	01	H9589_003_0	9	7	Eyewear	10		18b;	1	750.00	1	50	50	2			2	
H9615	007	0	1	04	01	H9615_007_0	9	1	40%	01	5;6;8a1;8a2;8b2;9a;9b;11a;11b;11c;15;17b;		2		1	40	40	2			2	
H9615	007	0	1	04	01	H9615_007_0	9	2	$60 Copay	11	3-1;3-2;3-3;7a;7c;7d;7e;7f;7g;7h;7i;8b1;8b3;9c;16b;17a;18a;	14b;17a;18a;	2		2			1	60.00	60.00	2	
H9615	007	0	1	04	01	H9615_007_0	9	3	$20	01	7b;		2		2			1	20.00	20.00	2	
H9615	007	0	1	04	01	H9615_007_0	9	4	$0	11	9d;14a;14d;14e;	9d;14c;16a;	2		2			2			2	
H9615	007	0	1	04	01	H9615_007_0	9	5	$150 Copay	01	10a;		2		2			1	150.00	150.00	2	
H9615	007	0	1	04	01	H9615_007_0	9	6	50% Coinsurance	10		13a;	2		1	50	50	2			2	
H9615	007	0	1	04	01	H9615_007_0	9	7	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H9615	007	0	1	04	01	H9615_007_0	9	8	20%	01	12;		2		1	20	20	2			2	
H9615	008	0	1	04	01	H9615_008_0	6	1	40%	01	5;6;8a1;8a2;8b2;9a;9b;11a;11b;11c;15;17b;		2		1	40	40	2			2	
H9615	008	0	1	04	01	H9615_008_0	6	2	$60 Copay	11	3-1;3-2;3-3;7a;7c;7d;7e;7f;7g;7h;7i;8b1;8b3;9c;16b;17a;18a;	14b;17a;18a;	2		2			1	60.00	60.00	2	
H9615	008	0	1	04	01	H9615_008_0	6	3	$20	01	7b;		2		2			1	20.00	20.00	2	
H9615	008	0	1	04	01	H9615_008_0	6	4	$0	11	9d;14a;14d;14e;	9d;14c;	2		2			2			2	
H9615	008	0	1	04	01	H9615_008_0	6	5	$250 Copay	01	10a;		2		2			1	250.00	250.00	2	
H9615	008	0	1	04	01	H9615_008_0	6	6	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H9615	008	0	1	04	01	H9615_008_0	6	7	20%	01	12;		2		1	20	20	2			2	
H9615	009	0	1	04	01	H9615_009_0	7	1	40%	01	5;6;8a1;8a2;8b2;9a;9b;11a;11b;11c;15;17b;		2		1	40	40	2			2	
H9615	009	0	1	04	01	H9615_009_0	7	2	$60 Copay	11	3-1;3-2;3-3;7a;7c;7d;7e;7f;7g;7h;7i;8b1;8b3;9c;16b;17a;18a;	14b;17a;18a;	2		2			1	60.00	60.00	2	
H9615	009	0	1	04	01	H9615_009_0	7	3	$20	01	7b;		2		2			1	20.00	20.00	2	
H9615	009	0	1	04	01	H9615_009_0	7	4	$0	11	9d;14a;14d;14e;	9d;14c;16a;	2		2			2			2	
H9615	009	0	1	04	01	H9615_009_0	7	5	$150 Copay	01	10a;		2		2			1	150.00	150.00	2	
H9615	009	0	1	04	01	H9615_009_0	7	6	50% Coinsurance	10		13a;	2		1	50	50	2			2	
H9615	009	0	1	04	01	H9615_009_0	7	7	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H9615	009	0	1	04	01	H9615_009_0	7	8	20%	01	12;		2		1	20	20	2			2	
H9615	010	0	1	04	01	H9615_010_0	7	1	40%	01	5;6;8a1;8a2;8b2;9a;9b;11a;11b;11c;15;17b;		2		1	40	40	2			2	
H9615	010	0	1	04	01	H9615_010_0	7	2	$60 Copay	11	3-1;3-2;3-3;7a;7c;7d;7e;7f;7g;7h;7i;8b1;8b3;9c;16b;17a;18a;	14b;17a;18a;	2		2			1	60.00	60.00	2	
H9615	010	0	1	04	01	H9615_010_0	7	3	$20	01	7b;		2		2			1	20.00	20.00	2	
H9615	010	0	1	04	01	H9615_010_0	7	4	$0	11	9d;14a;14d;14e;	9d;14c;	2		2			2			2	
H9615	010	0	1	04	01	H9615_010_0	7	5	$200 Copay	01	10a;		2		2			1	200.00	200.00	2	
H9615	010	0	1	04	01	H9615_010_0	7	6	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H9615	010	0	1	04	01	H9615_010_0	7	7	20%	01	12;		2		1	20	20	2			2	
H9615	012	0	1	04	01	H9615_012_0	6	1	40%	01	5;6;8a1;8a2;8b2;9a;9b;11a;11b;11c;15;17b;		2		1	40	40	2			2	
H9615	012	0	1	04	01	H9615_012_0	6	2	$60 Copay	11	3-1;3-2;3-3;7a;7c;7d;7e;7f;7g;7h;7i;8b1;8b3;9c;16b;17a;18a;	14b;17a;18a;	2		2			1	60.00	60.00	2	
H9615	012	0	1	04	01	H9615_012_0	6	3	$20	01	7b;		2		2			1	20.00	20.00	2	
H9615	012	0	1	04	01	H9615_012_0	6	4	$0	11	9d;14a;14d;14e;	9d;14c;	2		2			2			2	
H9615	012	0	1	04	01	H9615_012_0	6	5	$200 Copay	01	10a;		2		2			1	200.00	200.00	2	
H9615	012	0	1	04	01	H9615_012_0	6	6	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
H9615	012	0	1	04	01	H9615_012_0	6	7	20%	01	12;		2		1	20	20	2			2	
H9615	802	0	1	04	01	H9615_802_0	1	1		01	6;14a;		2		1	0	0	2			2	
H9615	802	0	1	04	01	H9615_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H9615	807	0	1	04	01	H9615_807_0	1	1		01	6;14a;		2		1	0	0	2			2	
H9615	807	0	1	04	01	H9615_807_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H9615	810	0	1	04	01	H9615_810_0	1	1		01	6;14a;		2		1	0	0	2			2	
H9615	810	0	1	04	01	H9615_810_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H9615	811	0	1	04	01	H9615_811_0	1	1		01	6;14a;		2		1	0	0	2			2	
H9615	811	0	1	04	01	H9615_811_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
H9808	004	0	1	04	01	H9808_004_0	6	1	$20 copay	11	7b;	14b;	2		2			1	20.00	20.00	2	
H9808	004	0	1	04	01	H9808_004_0	6	10	$300 Copay	01	9a;		2		2			1	300.00	300.00	2	
H9808	004	0	1	04	01	H9808_004_0	6	11	$10 to $25 Copay	01	8a1;8a2;8b3;		2		2			1	10.00	25.00	2	
H9808	004	0	1	04	01	H9808_004_0	6	12	$75 to $250 Copay	01	8b1;		2		2			1	75.00	250.00	2	
H9808	004	0	1	04	01	H9808_004_0	6	13	20% Coinsurance	01	11c;14d;14e;		2		1	20	20	2			2	
H9808	004	0	1	04	01	H9808_004_0	6	14	30% Coinsurance	01	8b2;9d;11a;11b;15;		2		1	30	30	2			2	
H9808	004	0	1	04	01	H9808_004_0	6	15	50% Coinsurance	01	17b;		2		1	50	50	2			2	
H9808	004	0	1	04	01	H9808_004_0	6	2	$25 copay	01	3-1;3-2;3-3;		2		2			1	25.00	25.00	2	
H9808	004	0	1	04	01	H9808_004_0	6	3	$30 copay	11	14a;	14c;17a;18a;	2		2			1	30.00	30.00	2	
H9808	004	0	1	04	01	H9808_004_0	6	4	$40 copay	01	7c;7i;		2		2			1	40.00	40.00	2	
H9808	004	0	1	04	01	H9808_004_0	6	5	$45 Copay	01	6;7a;7g;		2		2			1	45.00	45.00	2	
H9808	004	0	1	04	01	H9808_004_0	6	6	$50 Copay	01	7d;16b;17a;18a;		2		2			1	50.00	50.00	2	
H9808	004	0	1	04	01	H9808_004_0	6	7	$60 Copay	01	7e;7f;7h;9c;12;		2		2			1	60.00	60.00	2	
H9808	004	0	1	04	01	H9808_004_0	6	8	$150 Copay	01	5;		2		2			1	150.00	150.00	2	
H9808	004	0	1	04	01	H9808_004_0	6	9	$225 Copay	01	9b;10a;		2		2			1	225.00	225.00	2	
H9808	005	0	1	04	01	H9808_005_0	5	1	$20 Copay	11	3-1;3-2;3-3;7b;	14b;	2		2			1	20.00	20.00	2	
H9808	005	0	1	04	01	H9808_005_0	5	10	$75 to $200 Copay	01	8b1;		2		2			1	75.00	200.00	2	
H9808	005	0	1	04	01	H9808_005_0	5	11	20% Coinsurance	01	11c;14d;14e;		2		1	20	20	2			2	
H9808	005	0	1	04	01	H9808_005_0	5	12	30% Coinsurance	01	8b2;9d;11a;11b;15;		2		1	30	30	2			2	
H9808	005	0	1	04	01	H9808_005_0	5	13	50% Coinsurance	11	17b;	17b;	2		1	50	50	2			2	
H9808	005	0	1	04	01	H9808_005_0	5	14	$50 Copay	01	7d;		2		2			1	50.00	50.00	2	
H9808	005	0	1	04	01	H9808_005_0	5	15	$20 to $50 Copay	01	8a2;		2		2			1	20.00	50.00	2	
H9808	005	0	1	04	01	H9808_005_0	5	2	$30 Copay	11	7c;7i;14a;	14c;17a;18a;	2		2			1	30.00	30.00	2	
H9808	005	0	1	04	01	H9808_005_0	5	3	$40 Copay	01	6;7a;7g;16b;17a;18a;		2		2			1	40.00	40.00	2	
H9808	005	0	1	04	01	H9808_005_0	5	4	$55 Copay	01	7e;7h;9c;12;		2		2			1	55.00	55.00	2	
H9808	005	0	1	04	01	H9808_005_0	5	5	$60 Copay	01	7f;		2		2			1	60.00	60.00	2	
H9808	005	0	1	04	01	H9808_005_0	5	6	$125 Copay	01	5;		2		2			1	125.00	125.00	2	
H9808	005	0	1	04	01	H9808_005_0	5	7	$200 Copay	01	9b;10a;		2		2			1	200.00	200.00	2	
H9808	005	0	1	04	01	H9808_005_0	5	8	$300 Copay	01	9a;		2		2			1	300.00	300.00	2	
H9808	005	0	1	04	01	H9808_005_0	5	9	$10 to $25 Copay	01	8a1;8b3;		2		2			1	10.00	25.00	2	
H9808	804	0	1	04	01	H9808_804_0	1	1		01	6;14a;		2		1	0	0	2			2	
H9808	804	0	1	04	01	H9808_804_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R0110	001	0	1	31	11	R0110_001_0	2	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
R0110	001	0	1	31	11	R0110_001_0	2	10		01	3-1;3-2;3-3;5;6;7c;7i;9a;9b;11b;15;		2		1	30	30	2			2	
R0110	001	0	1	31	11	R0110_001_0	2	11		01	14a;		2		1	30	30	1	0.00	50.00	2	
R0110	001	0	1	31	11	R0110_001_0	2	12		01	8a1;8a2;8b3;14e;		2		1	30	30	1	35.00	50.00	2	
R0110	001	0	1	31	11	R0110_001_0	2	13		01	8b1;8b2;9c;		2		1	30	30	1	50.00	50.00	2	
R0110	001	0	1	31	11	R0110_001_0	2	14		10		13c;14c;16a;16b;	2		1	50	55	2			2	
R0110	001	0	1	31	11	R0110_001_0	2	15		10		13b;	1	30.00	1	50	50	2			2	
R0110	001	0	1	31	11	R0110_001_0	2	2		11	7a;	14b;	2		2			1	35.00	35.00	2	
R0110	001	0	1	31	11	R0110_001_0	2	3		01	7g;14d;		2		2			1	35.00	50.00	2	
R0110	001	0	1	31	11	R0110_001_0	2	4		01	7b;7d;7e;7f;7h;16b;17a;18a;		2		2			1	50.00	50.00	2	
R0110	001	0	1	31	11	R0110_001_0	2	5		10		18b;	2		2			1	699.00	999.00	2	
R0110	001	0	1	31	11	R0110_001_0	2	6		01	11a;		2		1	17	17	2			2	
R0110	001	0	1	31	11	R0110_001_0	2	7		01	12;		2		1	20	20	2			2	
R0110	001	0	1	31	11	R0110_001_0	2	8		01	10a;		2		1	20	20	1	265.00	265.00	2	
R0110	001	0	1	31	11	R0110_001_0	2	9		01	11c;		2		1	20	30	2			2	
R0110	002	0	1	31	11	R0110_002_0	2	1		11	9d;17b;	9d;17a;18a;	2		2			1	0.00	0.00	2	
R0110	002	0	1	31	11	R0110_002_0	2	10		10		13b;	1	25.00	1	50	50	2			2	
R0110	002	0	1	31	11	R0110_002_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
R0110	002	0	1	31	11	R0110_002_0	2	3		01	11a;		2		1	13	13	2			2	
R0110	002	0	1	31	11	R0110_002_0	2	4		01	12;		2		1	20	20	2			2	
R0110	002	0	1	31	11	R0110_002_0	2	5		01	10a;		2		1	20	20	1	265.00	265.00	2	
R0110	002	0	1	31	11	R0110_002_0	2	6		01	11c;		2		1	25	30	2			2	
R0110	002	0	1	31	11	R0110_002_0	2	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
R0110	002	0	1	31	11	R0110_002_0	2	8		01	14a;		2		1	30	30	1	0.00	0.00	2	
R0110	002	0	1	31	11	R0110_002_0	2	9		10		13c;14c;	2		1	50	50	2			2	
R0110	003	0	1	31	11	R0110_003_0	3	1		11	6;9d;14a;14d;14e;17b;	9d;14b;17a;18a;	2		2			1	0.00	0.00	2	
R0110	003	0	1	31	11	R0110_003_0	3	10		01	7d;7f;8b2;9c;16b;17a;18a;		2		2			1	40.00	60.00	2	
R0110	003	0	1	31	11	R0110_003_0	3	11		10		18b;	2		2			1	699.00	999.00	2	
R0110	003	0	1	31	11	R0110_003_0	3	12		01	11a;11b;11c;12;15;		2		1	17	20	2			2	
R0110	003	0	1	31	11	R0110_003_0	3	13		01	10a;		2		1	20	20	1	265.00	265.00	2	
R0110	003	0	1	31	11	R0110_003_0	3	14		10		13c;14c;16a;16b;	2		1	50	55	2			2	
R0110	003	0	1	31	11	R0110_003_0	3	15		10		13b;	1	25.00	1	50	50	2			2	
R0110	003	0	1	31	11	R0110_003_0	3	2		01	8a1;8a2;8b3;		2		2			1	0.00	100.00	2	
R0110	003	0	1	31	11	R0110_003_0	3	3		01	8b1;		2		2			1	0.00	225.00	2	
R0110	003	0	1	31	11	R0110_003_0	3	4		01	3-1;3-2;3-3;7a;7c;7i;		2		2			1	15.00	15.00	2	
R0110	003	0	1	31	11	R0110_003_0	3	5		01	7g;		2		2			1	15.00	50.00	2	
R0110	003	0	1	31	11	R0110_003_0	3	6		01	7b;		2		2			1	20.00	20.00	2	
R0110	003	0	1	31	11	R0110_003_0	3	7		01	9b;		2		2			1	225.00	225.00	2	
R0110	003	0	1	31	11	R0110_003_0	3	8		01	9a;		2		2			1	275.00	275.00	2	
R0110	003	0	1	31	11	R0110_003_0	3	9		01	5;7e;7h;		2		2			1	40.00	40.00	2	
R0110	801	0	1	31	11	R0110_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
R0110	801	0	1	31	11	R0110_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R0110	802	0	1	31	11	R0110_802_0	2	1		01	6;14a;		2		1	0	0	2			2	
R0110	802	0	1	31	11	R0110_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R0110	803	0	1	31	11	R0110_803_0	2	1		01	6;14a;		2		1	0	0	2			2	
R0110	803	0	1	31	11	R0110_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R0865	001	0	1	31	11	R0865_001_0	2	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
R0865	001	0	1	31	11	R0865_001_0	2	2		01	11a;11b;11c;12;		2		1	20	20	2			2	
R0865	001	0	1	31	11	R0865_001_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
R0865	001	0	1	31	11	R0865_001_0	2	4		01	15;		2		1	20	30	2			2	
R0865	001	0	1	31	11	R0865_001_0	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	14b;	2		1	30	30	2			2	
R0865	001	0	1	31	11	R0865_001_0	2	6		01	14a;		2		1	30	30	1	0.00	0.00	2	
R0865	001	0	1	31	11	R0865_001_0	2	7		10		13c;14c;16a;	2		1	50	50	2			2	
R0865	001	0	1	31	11	R0865_001_0	2	8		10		13b;	1	45.00	1	50	50	2			2	
R0865	001	0	1	31	11	R0865_001_0	2	9		10		16b;	2		1	50	80	2			2	
R0865	003	0	1	31	11	R0865_003_0	2	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
R0865	003	0	1	31	11	R0865_003_0	2	2		10		18b;	2		2			1	499.00	799.00	2	
R0865	003	0	1	31	11	R0865_003_0	2	3		01	11a;12;		2		1	20	20	2			2	
R0865	003	0	1	31	11	R0865_003_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
R0865	003	0	1	31	11	R0865_003_0	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
R0865	003	0	1	31	11	R0865_003_0	2	6		01	14a;		2		1	30	30	1	0.00	0.00	2	
R0865	003	0	1	31	11	R0865_003_0	2	7		10		13c;14c;	2		1	50	50	2			2	
R0865	003	0	1	31	11	R0865_003_0	2	8		10		13b;	1	45.00	1	50	50	2			2	
R0865	801	0	1	31	11	R0865_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
R0865	801	0	1	31	11	R0865_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R0865	802	0	1	31	11	R0865_802_0	2	1		01	6;14a;		2		1	0	0	2			2	
R0865	802	0	1	31	11	R0865_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R0865	803	0	1	31	11	R0865_803_0	3	1		01	6;14a;		2		1	0	0	2			2	
R0865	803	0	1	31	11	R0865_803_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R0923	001	0	1	31	11	R0923_001_0	2	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
R0923	001	0	1	31	11	R0923_001_0	2	2		01	11a;11b;11c;12;		2		1	20	20	2			2	
R0923	001	0	1	31	11	R0923_001_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
R0923	001	0	1	31	11	R0923_001_0	2	4		01	15;		2		1	20	30	2			2	
R0923	001	0	1	31	11	R0923_001_0	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	14b;	2		1	30	30	2			2	
R0923	001	0	1	31	11	R0923_001_0	2	6		01	14a;		2		1	30	30	1	0.00	0.00	2	
R0923	001	0	1	31	11	R0923_001_0	2	7		10		13c;14c;16a;16b;	2		1	50	50	2			2	
R0923	001	0	1	31	11	R0923_001_0	2	8		10		13b;	1	45.00	1	50	50	2			2	
R0923	002	0	1	31	11	R0923_002_0	2	1		11	9d;17b;	9d;	2		2			1	0.00	0.00	2	
R0923	002	0	1	31	11	R0923_002_0	2	2		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;12;14d;14e;15;16b;17a;18a;	14b;	2		1	20	20	2			2	
R0923	002	0	1	31	11	R0923_002_0	2	3		01	14a;		2		1	20	20	1	0.00	0.00	2	
R0923	002	0	1	31	11	R0923_002_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
R0923	002	0	1	31	11	R0923_002_0	2	5		10		13c;14c;	2		1	50	50	2			2	
R0923	801	0	1	31	11	R0923_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
R0923	801	0	1	31	11	R0923_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R0923	802	0	1	31	11	R0923_802_0	2	1		01	6;14a;		2		1	0	0	2			2	
R0923	802	0	1	31	11	R0923_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R0923	803	0	1	31	11	R0923_803_0	2	1		01	6;14a;		2		1	0	0	2			2	
R0923	803	0	1	31	11	R0923_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R1390	001	0	1	31	11	R1390_001_0	2	1		11	9d;	9d;17a;18a;	2		2			1	0.00	0.00	2	
R1390	001	0	1	31	11	R1390_001_0	2	2		10		18b;	2		2			1	699.00	999.00	2	
R1390	001	0	1	31	11	R1390_001_0	2	3		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;	14b;	2		1	20	20	2			2	
R1390	001	0	1	31	11	R1390_001_0	2	4		01	14a;		2		1	20	20	1	0.00	0.00	2	
R1390	001	0	1	31	11	R1390_001_0	2	5		01	10a;		2		1	20	20	1	265.00	265.00	2	
R1390	001	0	1	31	11	R1390_001_0	2	6		10		13c;14c;	2		1	50	50	2			2	
R1390	001	0	1	31	11	R1390_001_0	2	7		10		13b;	1	30.00	1	50	50	2			2	
R1390	002	0	1	31	11	R1390_002_0	3	1		11	6;9d;14a;14d;14e;17b;	9d;14b;17a;18a;	2		2			1	0.00	0.00	2	
R1390	002	0	1	31	11	R1390_002_0	3	10		10		18b;	2		2			1	699.00	999.00	2	
R1390	002	0	1	31	11	R1390_002_0	3	11		01	11a;11b;11c;12;15;		2		1	20	20	2			2	
R1390	002	0	1	31	11	R1390_002_0	3	12		01	10a;		2		1	20	20	1	265.00	265.00	2	
R1390	002	0	1	31	11	R1390_002_0	3	13		01	8b2;		2		1	20	20	1	50.00	50.00	2	
R1390	002	0	1	31	11	R1390_002_0	3	14		10		13c;14c;	2		1	50	50	2			2	
R1390	002	0	1	31	11	R1390_002_0	3	15		10		13b;	1	25.00	1	50	50	2			2	
R1390	002	0	1	31	11	R1390_002_0	3	2		01	8a1;8a2;17a;		2		2			1	0.00	100.00	2	
R1390	002	0	1	31	11	R1390_002_0	3	3		01	7b;7c;7g;7i;8b3;		2		2			1	15.00	100.00	2	
R1390	002	0	1	31	11	R1390_002_0	3	4		01	3-1;3-2;3-3;7a;		2		2			1	15.00	15.00	2	
R1390	002	0	1	31	11	R1390_002_0	3	5		01	9b;		2		2			1	310.00	310.00	2	
R1390	002	0	1	31	11	R1390_002_0	3	6		01	9a;		2		2			1	360.00	360.00	2	
R1390	002	0	1	31	11	R1390_002_0	3	7		01	5;7e;7h;9c;		2		2			1	40.00	100.00	2	
R1390	002	0	1	31	11	R1390_002_0	3	8		01	8b1;		2		2			1	50.00	360.00	2	
R1390	002	0	1	31	11	R1390_002_0	3	9		01	7d;7f;16b;18a;		2		2			1	50.00	50.00	2	
R1390	801	0	1	31	11	R1390_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
R1390	801	0	1	31	11	R1390_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R1390	802	0	1	31	11	R1390_802_0	2	1		01	6;14a;		2		1	0	0	2			2	
R1390	802	0	1	31	11	R1390_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R1390	803	0	1	31	11	R1390_803_0	2	1		01	6;14a;		2		1	0	0	2			2	
R1390	803	0	1	31	11	R1390_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R1532	001	0	1	31	11	R1532_001_0	2	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
R1532	001	0	1	31	11	R1532_001_0	2	2		01	11a;		2		1	14	14	2			2	
R1532	001	0	1	31	11	R1532_001_0	2	3		01	12;15;		2		1	20	20	2			2	
R1532	001	0	1	31	11	R1532_001_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
R1532	001	0	1	31	11	R1532_001_0	2	5		10		18a;18b;	2		1	25	25	2			2	
R1532	001	0	1	31	11	R1532_001_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13c;14b;14c;16a;	2		1	50	50	2			2	
R1532	001	0	1	31	11	R1532_001_0	2	7		01	14a;		2		1	50	50	1	0.00	0.00	2	
R1532	002	0	1	31	11	R1532_002_0	2	1		11	9d;	9d;17a;	2		2			1	0.00	0.00	2	
R1532	002	0	1	31	11	R1532_002_0	2	2		01	11a;11b;11c;12;		2		1	20	20	2			2	
R1532	002	0	1	31	11	R1532_002_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
R1532	002	0	1	31	11	R1532_002_0	2	4		01	15;		2		1	20	40	2			2	
R1532	002	0	1	31	11	R1532_002_0	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;17b;18a;	14b;	2		1	40	40	2			2	
R1532	002	0	1	31	11	R1532_002_0	2	6		01	14a;		2		1	40	40	1	0.00	0.00	2	
R1532	002	0	1	31	11	R1532_002_0	2	7		10		13c;14c;16a;16b;	2		1	50	50	2			2	
R1532	002	0	1	31	11	R1532_002_0	2	8		10		13b;	1	25.00	1	50	50	2			2	
R1532	801	0	1	31	11	R1532_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
R1532	801	0	1	31	11	R1532_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R1532	802	0	1	31	11	R1532_802_0	2	1		01	6;14a;		2		1	0	0	2			2	
R1532	802	0	1	31	11	R1532_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R1532	803	0	1	31	11	R1532_803_0	2	1		01	6;14a;		2		1	0	0	2			2	
R1532	803	0	1	31	11	R1532_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R1548	001	0	1	31	11	R1548_001_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;16b;17a;18a;	7f;9d;17a;18a;	2		1	40	40	2			2	
R1548	001	0	1	31	11	R1548_001_0	4	2	Group 2	01	14a;		2		1	0	40	2			2	
R1548	001	0	1	31	11	R1548_001_0	4	3	Group 3	01	10a;12;		2		1	20	20	2			2	
R1548	001	0	1	31	11	R1548_001_0	4	4	Group 4	11	8a2;17b;	14c;16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
R1548	001	0	1	31	11	R1548_001_0	4	5	Group 5	10		13b;	1	200.00	2			1	0.00	0.00	2	
R1548	001	0	1	31	11	R1548_001_0	4	6	Group 6	10		10b;	2		1	75	75	2			2	
R1548	001	0	1	31	11	R1548_001_0	4	7	Group 7	01	15;		2		1	30	30	2			2	
R3175	003	0	1	31	11	R3175_003_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;16b;17a;18a;	7b;7f;9d;13a;	2		1	30	30	2			2	
R3175	003	0	1	31	11	R3175_003_0	3	2	Group 2	01	14a;		2		1	0	30	2			2	
R3175	003	0	1	31	11	R3175_003_0	3	3	Group 3	11	8a2;17b;	14c;16a;16b;	2		2			1	0.00	0.00	2	
R3175	003	0	1	31	11	R3175_003_0	3	4	Group 4	01	10a;12;15;		2		1	20	20	2			2	
R3175	003	0	1	31	11	R3175_003_0	3	5	Group 5	10		13b;	1	140.00	2			1	0.00	0.00	2	
R3175	801	0	1	31	11	R3175_801_0	1	1		01	6;14a;		2		1	0	0	2			2	
R3175	801	0	1	31	11	R3175_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R3175	802	0	1	31	11	R3175_802_0	1	1		01	6;14a;		2		1	0	0	2			2	
R3175	802	0	1	31	11	R3175_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R3332	001	0	1	31	11	R3332_001_0	13	1	50%	01	3-1;3-2;3-3;6;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;11a;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;		2		1	50	50	2			2	
R3332	001	0	1	31	11	R3332_001_0	13	2	Mental Health	01	5;7e;7h;9c;		2		2			1	40.00	40.00	2	
R3332	001	0	1	31	11	R3332_001_0	13	3	Ambulance	01	10a;		2		2			1	250.00	250.00	2	
R3332	001	0	1	31	11	R3332_001_0	13	4	Dialysis	01	12;		2		1	20	20	2			2	
R3332	001	0	1	31	11	R3332_001_0	13	5	Health Education & Fitness	10		14c;	2		2			2			2	
R3332	001	0	1	31	11	R3332_001_0	13	6	Hearing Aids	10		18b;	2		2			1	699.00	999.00	2	
R3332	001	0	1	31	11	R3332_001_0	13	7	Hearing Exam & Fitting and Evaluation	10		18a;	2		2			1	0.00	45.00	2	
R3332	001	0	1	31	11	R3332_001_0	13	8	Routine Eye Exam	10		17a;	2		2			2			2	
R3392	001	0	1	31	11	R3392_001_0	4	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
R3392	001	0	1	31	11	R3392_001_0	4	10		01	3-1;3-2;3-3;7c;7i;8a1;8a2;8b1;8b2;8b3;14e;		2		1	30	30	1	45.00	45.00	2	
R3392	001	0	1	31	11	R3392_001_0	4	11		10		13c;14c;	2		1	50	50	2			2	
R3392	001	0	1	31	11	R3392_001_0	4	12		10		13b;	1	45.00	1	50	50	2			2	
R3392	001	0	1	31	11	R3392_001_0	4	2		11	7b;7e;7h;	14b;	2		2			1	40.00	40.00	2	
R3392	001	0	1	31	11	R3392_001_0	4	3		01	7a;7d;7f;7g;14d;16b;17a;18a;		2		2			1	45.00	45.00	2	
R3392	001	0	1	31	11	R3392_001_0	4	4		10		18b;	2		2			1	699.00	999.00	2	
R3392	001	0	1	31	11	R3392_001_0	4	5		01	11a;11b;12;		2		1	20	20	2			2	
R3392	001	0	1	31	11	R3392_001_0	4	6		01	10a;		2		1	20	20	1	265.00	265.00	2	
R3392	001	0	1	31	11	R3392_001_0	4	7		01	5;6;9a;9b;11c;15;		2		1	30	30	2			2	
R3392	001	0	1	31	11	R3392_001_0	4	8		01	14a;		2		1	30	30	1	0.00	45.00	2	
R3392	001	0	1	31	11	R3392_001_0	4	9		01	9c;		2		1	30	30	1	40.00	40.00	2	
R3392	002	0	1	31	11	R3392_002_0	3	1		11	6;9d;14a;14d;14e;17b;	9d;14b;17a;18a;	2		2			1	0.00	0.00	2	
R3392	002	0	1	31	11	R3392_002_0	3	10		10		18b;	2		2			1	699.00	999.00	2	
R3392	002	0	1	31	11	R3392_002_0	3	11		01	8b2;11a;11b;11c;12;15;		2		1	20	20	2			2	
R3392	002	0	1	31	11	R3392_002_0	3	12		01	10a;		2		1	20	20	1	265.00	265.00	2	
R3392	002	0	1	31	11	R3392_002_0	3	13		01	7d;7g;8a1;		2		1	25	25	1	0.00	100.00	2	
R3392	002	0	1	31	11	R3392_002_0	3	14		10		13c;14c;16a;16b;	2		1	50	50	2			2	
R3392	002	0	1	31	11	R3392_002_0	3	15		10		13b;	1	25.00	1	50	50	2			2	
R3392	002	0	1	31	11	R3392_002_0	3	2		01	8a2;8b3;17a;		2		2			1	0.00	100.00	2	
R3392	002	0	1	31	11	R3392_002_0	3	3		01	3-1;3-2;3-3;7a;7b;		2		2			1	20.00	20.00	2	
R3392	002	0	1	31	11	R3392_002_0	3	4		01	7c;7i;		2		2			1	20.00	40.00	2	
R3392	002	0	1	31	11	R3392_002_0	3	5		01	9a;9b;		2		2			1	310.00	360.00	2	
R3392	002	0	1	31	11	R3392_002_0	3	6		01	9c;		2		2			1	40.00	100.00	2	
R3392	002	0	1	31	11	R3392_002_0	3	7		01	5;7e;7h;		2		2			1	40.00	40.00	2	
R3392	002	0	1	31	11	R3392_002_0	3	8		01	8b1;		2		2			1	50.00	360.00	2	
R3392	002	0	1	31	11	R3392_002_0	3	9		01	7f;16b;18a;		2		2			1	50.00	50.00	2	
R3392	801	0	1	31	11	R3392_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
R3392	801	0	1	31	11	R3392_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R3392	802	0	1	31	11	R3392_802_0	2	1		01	6;14a;		2		1	0	0	2			2	
R3392	802	0	1	31	11	R3392_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R3392	803	0	1	31	11	R3392_803_0	2	1		01	6;14a;		2		1	0	0	2			2	
R3392	803	0	1	31	11	R3392_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R3444	008	0	1	31	11	R3444_008_0	3	1	Group 1	11	7e;7h;8a1;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;12;15;17b;	9d;	2		1	20	20	2			2	
R3444	008	0	1	31	11	R3444_008_0	3	2	Group 2	11	6;7a;8a2;14a;14d;18a;	7f;10b;16a;16b;17a;17b;18a;18b;	2		2			1	0.00	0.00	2	
R3444	008	0	1	31	11	R3444_008_0	3	3	Group 3	01	14e;		2		1	20	20	1	0.00	0.00	2	
R3444	008	0	1	31	11	R3444_008_0	3	4	Group 4	10		13b;	1	55.00	2			1	0.00	0.00	2	
R3444	008	0	1	31	11	R3444_008_0	3	5	Group 5	01	11c;		2		1	20	30	2			2	
R3444	008	0	1	31	11	R3444_008_0	3	6	Group 6	01	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;		2		1	19	19	2			2	
R3444	008	0	1	31	11	R3444_008_0	3	7	Group 7	01	7g;		2		1	0	19	2			2	
R3444	008	0	1	31	11	R3444_008_0	3	8	Group 8	01	5;		2		2			1	55.00	55.00	2	
R3444	009	0	1	31	11	R3444_009_0	3	1	Group 1	01	7d;		2		2			1	45.00	45.00	2	
R3444	009	0	1	31	11	R3444_009_0	3	10	Group 10	01	8a2;		2		2			1	10.00	10.00	2	
R3444	009	0	1	31	11	R3444_009_0	3	11	Group 11	11	7f;9d;14a;14d;14e;17b;	7f;9d;14c;16b;17b;	2		2			1	0.00	0.00	2	
R3444	009	0	1	31	11	R3444_009_0	3	12	Group 12	10		18b;	2		2			1	330.00	380.00	2	
R3444	009	0	1	31	11	R3444_009_0	3	13	Group 13	01	10a;		2		2			1	250.00	250.00	2	
R3444	009	0	1	31	11	R3444_009_0	3	14	Group 14	01	8b3;		2		2			1	14.00	14.00	2	
R3444	009	0	1	31	11	R3444_009_0	3	2	Group 2	01	6;11a;		2		1	50	50	2			2	
R3444	009	0	1	31	11	R3444_009_0	3	3	Group 3	01	5;		2		2			1	55.00	55.00	2	
R3444	009	0	1	31	11	R3444_009_0	3	4	Group 4	11	3-1;3-2;3-3;7b;17a;	16a;17a;	2		2			1	20.00	20.00	2	
R3444	009	0	1	31	11	R3444_009_0	3	5	Group 5	01	7c;7i;		2		2			1	40.00	40.00	2	
R3444	009	0	1	31	11	R3444_009_0	3	6	Group 6	01	7e;7h;9c;		2		2			1	30.00	40.00	2	
R3444	009	0	1	31	11	R3444_009_0	3	7	Group 7	11	7a;18a;	18a;	2		2			1	15.00	15.00	2	
R3444	009	0	1	31	11	R3444_009_0	3	8	Group 8	01	8a1;8b1;8b2;9a;9b;11b;11c;12;15;16b;		2		1	20	20	2			2	
R3444	009	0	1	31	11	R3444_009_0	3	9	Group 9	01	7g;		2		2			1	15.00	45.00	2	
R3444	011	0	1	31	11	R3444_011_0	3	1	Group 1	11	8a1;8b1;8b2;8b3;9a;9b;9d;10a;11a;11b;12;15;17b;	9d;	2		1	20	20	2			2	
R3444	011	0	1	31	11	R3444_011_0	3	2	Group 2	11	6;7a;8a2;14a;14d;18a;	7f;10b;14c;16a;16b;17a;17b;18a;18b;	2		2			1	0.00	0.00	2	
R3444	011	0	1	31	11	R3444_011_0	3	3	Group 3	01	11c;		2		1	20	30	2			2	
R3444	011	0	1	31	11	R3444_011_0	3	4	Group  4	10		13b;	1	150.00	2			1	0.00	0.00	2	
R3444	011	0	1	31	11	R3444_011_0	3	5	Group 5	01	14e;		2		1	20	20	1	0.00	0.00	2	
R3444	011	0	1	31	11	R3444_011_0	3	6	Group 6	01	3-1;3-2;3-3;7b;7c;7d;7e;7f;7h;7i;9c;16b;17a;		2		1	19	19	2			2	
R3444	011	0	1	31	11	R3444_011_0	3	7	Group 7	01	7g;		2		1	0	19	2			2	
R3444	011	0	1	31	11	R3444_011_0	3	8	Group 8	01	5;		2		2			1	55.00	55.00	2	
R3444	012	0	1	31	11	R3444_012_0	3	1	Group 1	11	7d;7f;	7f;	2		2			1	50.00	50.00	2	
R3444	012	0	1	31	11	R3444_012_0	3	10	Group 10	11	3-1;3-2;3-3;7b;17a;	16a;17a;	2		2			1	20.00	20.00	2	
R3444	012	0	1	31	11	R3444_012_0	3	11	Group 11	11	9d;14a;14d;14e;17b;	9d;14b;14c;16b;17b;	2		2			1	0.00	0.00	2	
R3444	012	0	1	31	11	R3444_012_0	3	12	Group 12	10		18b;	2		2			1	330.00	380.00	2	
R3444	012	0	1	31	11	R3444_012_0	3	13	Group 13	01	10a;		2		2			1	250.00	250.00	2	
R3444	012	0	1	31	11	R3444_012_0	3	14	Group 14	01	7g;		2		2			1	15.00	50.00	2	
R3444	012	0	1	31	11	R3444_012_0	3	15	Group 15	01	8a2;		2		2			1	10.00	10.00	2	
R3444	012	0	1	31	11	R3444_012_0	3	2	Group 2	01	6;		2		1	50	50	2			2	
R3444	012	0	1	31	11	R3444_012_0	3	3	Group 3	01	5;		2		2			1	55.00	55.00	2	
R3444	012	0	1	31	11	R3444_012_0	3	4	Group 4	11	7a;18a;	18a;	2		2			1	15.00	15.00	2	
R3444	012	0	1	31	11	R3444_012_0	3	5	Group 5	01	7c;7i;		2		2			1	40.00	40.00	2	
R3444	012	0	1	31	11	R3444_012_0	3	6	Group 6	01	7e;7h;9c;		2		2			1	30.00	40.00	2	
R3444	012	0	1	31	11	R3444_012_0	3	7	Group 7	01	8b3;		2		2			1	14.00	14.00	2	
R3444	012	0	1	31	11	R3444_012_0	3	8	Group 8	01	8a1;8b1;8b2;9a;9b;11b;11c;12;15;16b;		2		1	20	20	2			2	
R3444	012	0	1	31	11	R3444_012_0	3	9	Group 9	01	11a;		2		1	45	45	2			2	
R3887	001	0	1	31	11	R3887_001_0	3	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
R3887	001	0	1	31	11	R3887_001_0	3	2		01	11a;		2		1	15	15	2			2	
R3887	001	0	1	31	11	R3887_001_0	3	3		01	12;		2		1	20	20	2			2	
R3887	001	0	1	31	11	R3887_001_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
R3887	001	0	1	31	11	R3887_001_0	3	5		10		18a;18b;	2		1	25	25	2			2	
R3887	001	0	1	31	11	R3887_001_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13c;14b;14c;16a;	2		1	50	50	2			2	
R3887	001	0	1	31	11	R3887_001_0	3	7		10		13b;	1	15.00	1	50	50	2			2	
R3887	001	0	1	31	11	R3887_001_0	3	8		01	14a;		2		1	50	50	1	0.00	0.00	2	
R3887	002	0	1	31	11	R3887_002_0	3	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
R3887	002	0	1	31	11	R3887_002_0	3	2		01	12;		2		1	20	20	2			2	
R3887	002	0	1	31	11	R3887_002_0	3	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
R3887	002	0	1	31	11	R3887_002_0	3	4		10		18a;18b;	2		1	25	25	2			2	
R3887	002	0	1	31	11	R3887_002_0	3	5		01	11a;		2		1	30	30	2			2	
R3887	002	0	1	31	11	R3887_002_0	3	6		01	11b;11c;		2		1	40	40	2			2	
R3887	002	0	1	31	11	R3887_002_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;15;16b;17a;18a;	13c;14b;14c;16a;	2		1	50	50	2			2	
R3887	002	0	1	31	11	R3887_002_0	3	8		10		13b;	1	15.00	1	50	50	2			2	
R3887	002	0	1	31	11	R3887_002_0	3	9		01	14a;		2		1	50	50	1	0.00	0.00	2	
R3887	801	0	1	31	11	R3887_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
R3887	801	0	1	31	11	R3887_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R3887	802	0	1	31	11	R3887_802_0	2	1		01	6;14a;		2		1	0	0	2			2	
R3887	802	0	1	31	11	R3887_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R3887	803	0	1	31	11	R3887_803_0	2	1		01	6;14a;		2		1	0	0	2			2	
R3887	803	0	1	31	11	R3887_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R4182	001	0	1	31	11	R4182_001_0	2	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
R4182	001	0	1	31	11	R4182_001_0	2	2		01	6;11a;11b;11c;12;		2		1	20	20	2			2	
R4182	001	0	1	31	11	R4182_001_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
R4182	001	0	1	31	11	R4182_001_0	2	4		01	15;		2		1	20	30	2			2	
R4182	001	0	1	31	11	R4182_001_0	2	5		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	14b;	2		1	30	30	2			2	
R4182	001	0	1	31	11	R4182_001_0	2	6		01	14a;		2		1	30	50	1	0.00	0.00	2	
R4182	001	0	1	31	11	R4182_001_0	2	7		10		13c;14c;	2		1	50	50	2			2	
R4182	001	0	1	31	11	R4182_001_0	2	8		10		13b;	1	25.00	1	50	50	2			2	
R4182	003	0	1	31	11	R4182_003_0	2	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
R4182	003	0	1	31	11	R4182_003_0	2	10		10		16b;	2		1	50	55	2			2	
R4182	003	0	1	31	11	R4182_003_0	2	2		01	6;12;		2		1	20	20	2			2	
R4182	003	0	1	31	11	R4182_003_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
R4182	003	0	1	31	11	R4182_003_0	2	4		01	8a1;15;		2		1	20	40	2			2	
R4182	003	0	1	31	11	R4182_003_0	2	5		01	11a;11b;11c;		2		1	25	25	2			2	
R4182	003	0	1	31	11	R4182_003_0	2	6		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	14b;	2		1	40	40	2			2	
R4182	003	0	1	31	11	R4182_003_0	2	7		01	14a;		2		1	40	50	1	0.00	0.00	2	
R4182	003	0	1	31	11	R4182_003_0	2	8		10		13c;14c;16a;	2		1	50	50	2			2	
R4182	003	0	1	31	11	R4182_003_0	2	9		10		13b;	1	25.00	1	50	50	2			2	
R4182	004	0	1	31	11	R4182_004_0	2	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
R4182	004	0	1	31	11	R4182_004_0	2	2		01	11a;12;		2		1	20	20	2			2	
R4182	004	0	1	31	11	R4182_004_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
R4182	004	0	1	31	11	R4182_004_0	2	4		01	15;		2		1	20	40	2			2	
R4182	004	0	1	31	11	R4182_004_0	2	5		01	11b;11c;		2		1	25	25	2			2	
R4182	004	0	1	31	11	R4182_004_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	14b;	2		1	40	40	2			2	
R4182	004	0	1	31	11	R4182_004_0	2	7		01	14a;		2		1	40	50	1	0.00	0.00	2	
R4182	004	0	1	31	11	R4182_004_0	2	8		10		13c;14c;	2		1	50	50	2			2	
R4182	004	0	1	31	11	R4182_004_0	2	9		10		13b;	1	25.00	1	50	50	2			2	
R4182	801	0	1	31	11	R4182_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
R4182	801	0	1	31	11	R4182_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R4182	802	0	1	31	11	R4182_802_0	2	1		01	6;14a;		2		1	0	0	2			2	
R4182	802	0	1	31	11	R4182_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R4182	803	0	1	31	11	R4182_803_0	2	1		01	6;14a;		2		1	0	0	2			2	
R4182	803	0	1	31	11	R4182_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R4845	001	0	1	31	11	R4845_001_0	2	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
R4845	001	0	1	31	11	R4845_001_0	2	2		01	11a;		2		1	15	15	2			2	
R4845	001	0	1	31	11	R4845_001_0	2	3		01	12;		2		1	20	20	2			2	
R4845	001	0	1	31	11	R4845_001_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
R4845	001	0	1	31	11	R4845_001_0	2	5		01	15;		2		1	20	40	2			2	
R4845	001	0	1	31	11	R4845_001_0	2	6		10		18a;18b;	2		1	25	25	2			2	
R4845	001	0	1	31	11	R4845_001_0	2	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	14b;	2		1	40	40	2			2	
R4845	001	0	1	31	11	R4845_001_0	2	8		01	14a;		2		1	40	40	1	0.00	0.00	2	
R4845	001	0	1	31	11	R4845_001_0	2	9		10		13c;14c;16a;16b;	2		1	50	50	2			2	
R4845	002	0	1	31	11	R4845_002_0	2	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
R4845	002	0	1	31	11	R4845_002_0	2	2		01	11a;11b;11c;12;		2		1	20	20	2			2	
R4845	002	0	1	31	11	R4845_002_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
R4845	002	0	1	31	11	R4845_002_0	2	4		01	15;		2		1	20	40	2			2	
R4845	002	0	1	31	11	R4845_002_0	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	14b;	2		1	40	40	2			2	
R4845	002	0	1	31	11	R4845_002_0	2	6		01	14a;		2		1	40	40	1	0.00	0.00	2	
R4845	002	0	1	31	11	R4845_002_0	2	7		10		13c;14c;	2		1	50	50	2			2	
R4845	002	0	1	31	11	R4845_002_0	2	8		10		13b;	1	25.00	1	50	50	2			2	
R4845	801	0	1	31	11	R4845_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
R4845	801	0	1	31	11	R4845_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R4845	802	0	1	31	11	R4845_802_0	2	1		01	6;14a;		2		1	0	0	2			2	
R4845	802	0	1	31	11	R4845_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R4845	803	0	1	31	11	R4845_803_0	2	1		01	6;14a;		2		1	0	0	2			2	
R4845	803	0	1	31	11	R4845_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R5329	001	0	1	31	11	R5329_001_0	4	1	Group 1	11	7a;9d;14a;14d;14e;17b;18a;	9d;14b;14c;16a;18a;	2		2			1	0.00	0.00	2	
R5329	001	0	1	31	11	R5329_001_0	4	10	Group 10	01	8a1;11b;11c;12;15;16b;		2		1	20	20	2			2	
R5329	001	0	1	31	11	R5329_001_0	4	11	Group 11	01	6;11a;		2		1	50	50	2			2	
R5329	001	0	1	31	11	R5329_001_0	4	12	Group 12	01	5;		2		2			1	55.00	55.00	2	
R5329	001	0	1	31	11	R5329_001_0	4	13	Group 13	10		18b;	2		2			1	330.00	380.00	2	
R5329	001	0	1	31	11	R5329_001_0	4	14	Group 14	01	7g;		2		2			1	0.00	25.00	2	
R5329	001	0	1	31	11	R5329_001_0	4	15	Group 15	01	8a2;		2		2			1	5.00	5.00	2	
R5329	001	0	1	31	11	R5329_001_0	4	2	Group 2	11	3-1;3-2;3-3;7b;17a;	17a;	2		2			1	20.00	20.00	2	
R5329	001	0	1	31	11	R5329_001_0	4	3	Group 3	11	7c;7d;7f;7i;	7f;	2		2			1	25.00	25.00	2	
R5329	001	0	1	31	11	R5329_001_0	4	4	Group 4	01	7e;7h;9c;		2		2			1	30.00	40.00	2	
R5329	001	0	1	31	11	R5329_001_0	4	5	Group 5	01	8b3;		2		2			1	14.00	14.00	2	
R5329	001	0	1	31	11	R5329_001_0	4	6	Group 6	01	8b2;		2		2			1	60.00	60.00	2	
R5329	001	0	1	31	11	R5329_001_0	4	7	Group 7	01	8b1;		2		2			1	100.00	100.00	2	
R5329	001	0	1	31	11	R5329_001_0	4	8	Group 8	01	9a;9b;		2		2			1	200.00	200.00	2	
R5329	001	0	1	31	11	R5329_001_0	4	9	Group 9	01	10a;		2		2			1	250.00	250.00	2	
R5342	001	0	1	31	11	R5342_001_0	3	1	Group 1	01	7a;		2		2			1	50.00	50.00	2	
R5342	001	0	1	31	11	R5342_001_0	3	10	Group 10	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
R5342	001	0	1	31	11	R5342_001_0	3	11	Group 11	01	14a;		2		1	0	40	2			2	
R5342	001	0	1	31	11	R5342_001_0	3	12	Group 12	01	6;11a;		2		1	50	50	2			2	
R5342	001	0	1	31	11	R5342_001_0	3	13	Group 13	01	7g;		2		2			1	50.00	75.00	2	
R5342	001	0	1	31	11	R5342_001_0	3	14	Group 14	01	8a2;		2		2			1	10.00	10.00	2	
R5342	001	0	1	31	11	R5342_001_0	3	2	Group 2	11	5;7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	75.00	75.00	2	
R5342	001	0	1	31	11	R5342_001_0	3	3	Group 3	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;11b;11c;14d;15;16b;17b;	14b;	2		1	40	40	2			2	
R5342	001	0	1	31	11	R5342_001_0	3	4	Group 4	01	8b3;		2		2			1	21.00	21.00	2	
R5342	001	0	1	31	11	R5342_001_0	3	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
R5342	001	0	1	31	11	R5342_001_0	3	6	Group 6	01	14e;		2		1	40	40	1	75.00	75.00	2	
R5342	001	0	1	31	11	R5342_001_0	3	7	Group 7	01	10a;		2		2			1	250.00	250.00	2	
R5342	001	0	1	31	11	R5342_001_0	3	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
R5342	001	0	1	31	11	R5342_001_0	3	9	Group 9	01	12;		2		1	20	20	2			2	
R5342	002	0	1	31	11	R5342_002_0	3	1	Group 1	01	7a;		2		2			1	50.00	50.00	2	
R5342	002	0	1	31	11	R5342_002_0	3	10	Group 10	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
R5342	002	0	1	31	11	R5342_002_0	3	11	Group 11	01	14a;		2		1	0	40	2			2	
R5342	002	0	1	31	11	R5342_002_0	3	12	Group 12	01	6;11a;		2		1	50	50	2			2	
R5342	002	0	1	31	11	R5342_002_0	3	13	Group 13	01	7g;		2		2			1	50.00	75.00	2	
R5342	002	0	1	31	11	R5342_002_0	3	14	Group 14	01	8b3;		2		2			1	21.00	21.00	2	
R5342	002	0	1	31	11	R5342_002_0	3	2	Group 2	11	5;7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	75.00	75.00	2	
R5342	002	0	1	31	11	R5342_002_0	3	3	Group 3	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;11b;11c;14d;15;16b;17b;	14b;	2		1	40	40	2			2	
R5342	002	0	1	31	11	R5342_002_0	3	4	Group 4	01	8a2;		2		2			1	10.00	10.00	2	
R5342	002	0	1	31	11	R5342_002_0	3	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
R5342	002	0	1	31	11	R5342_002_0	3	6	Group 6	01	14e;		2		1	40	40	1	75.00	75.00	2	
R5342	002	0	1	31	11	R5342_002_0	3	7	Group 7	01	10a;		2		2			1	250.00	250.00	2	
R5342	002	0	1	31	11	R5342_002_0	3	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
R5342	002	0	1	31	11	R5342_002_0	3	9	Group 9	01	12;		2		1	20	20	2			2	
R5342	005	0	1	31	11	R5342_005_0	3	1	Group 1	01	7a;		2		2			1	50.00	50.00	2	
R5342	005	0	1	31	11	R5342_005_0	3	10	Group 10	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
R5342	005	0	1	31	11	R5342_005_0	3	11	Group 11	01	14a;		2		1	0	40	2			2	
R5342	005	0	1	31	11	R5342_005_0	3	12	Group 12	11	6;11a;	16a;	2		1	50	50	2			2	
R5342	005	0	1	31	11	R5342_005_0	3	13	Group 13	01	7g;		2		2			1	50.00	75.00	2	
R5342	005	0	1	31	11	R5342_005_0	3	14	Group 14	01	8b3;		2		2			1	21.00	21.00	2	
R5342	005	0	1	31	11	R5342_005_0	3	2	Group 2	11	5;7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	75.00	75.00	2	
R5342	005	0	1	31	11	R5342_005_0	3	3	Group 3	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;11b;11c;14d;15;16b;17b;	14b;	2		1	40	40	2			2	
R5342	005	0	1	31	11	R5342_005_0	3	4	Group 4	01	8a2;		2		2			1	10.00	10.00	2	
R5342	005	0	1	31	11	R5342_005_0	3	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
R5342	005	0	1	31	11	R5342_005_0	3	6	Group 6	01	14e;		2		1	40	40	1	75.00	75.00	2	
R5342	005	0	1	31	11	R5342_005_0	3	7	Group 7	01	10a;		2		2			1	250.00	250.00	2	
R5342	005	0	1	31	11	R5342_005_0	3	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
R5342	005	0	1	31	11	R5342_005_0	3	9	Group 9	01	12;		2		1	20	20	2			2	
R5342	006	0	1	31	11	R5342_006_0	4	1	Group 1	01	7a;		2		2			1	50.00	50.00	2	
R5342	006	0	1	31	11	R5342_006_0	4	10	Group 10	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
R5342	006	0	1	31	11	R5342_006_0	4	11	Group 11	01	14a;		2		1	0	40	2			2	
R5342	006	0	1	31	11	R5342_006_0	4	12	Group 12	01	6;11a;		2		1	50	50	2			2	
R5342	006	0	1	31	11	R5342_006_0	4	13	Group 13	01	7g;		2		2			1	50.00	75.00	2	
R5342	006	0	1	31	11	R5342_006_0	4	14	Group 14	01	8b3;		2		2			1	21.00	21.00	2	
R5342	006	0	1	31	11	R5342_006_0	4	15	Group 15	10		16a;	2		1	75	75	2			2	
R5342	006	0	1	31	11	R5342_006_0	4	2	Group 2	11	5;7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	75.00	75.00	2	
R5342	006	0	1	31	11	R5342_006_0	4	3	Group 3	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;11b;11c;14d;15;16b;17b;	14b;	2		1	40	40	2			2	
R5342	006	0	1	31	11	R5342_006_0	4	4	Group 4	01	8a2;		2		2			1	10.00	10.00	2	
R5342	006	0	1	31	11	R5342_006_0	4	5	Group 5	10		18b;	2		2			1	330.00	380.00	2	
R5342	006	0	1	31	11	R5342_006_0	4	6	Group 6	01	14e;		2		1	40	40	1	75.00	75.00	2	
R5342	006	0	1	31	11	R5342_006_0	4	7	Group 7	01	10a;		2		2			1	250.00	250.00	2	
R5342	006	0	1	31	11	R5342_006_0	4	8	Group 8	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
R5342	006	0	1	31	11	R5342_006_0	4	9	Group 9	01	12;		2		1	20	20	2			2	
R5342	801	0	1	31	11	R5342_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
R5342	801	0	1	31	11	R5342_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R5342	802	0	1	31	11	R5342_802_0	1	1		01	6;14a;		2		1	0	0	2			2	
R5342	802	0	1	31	11	R5342_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R5342	803	0	1	31	11	R5342_803_0	1	1		01	6;14a;		2		1	0	0	2			2	
R5342	803	0	1	31	11	R5342_803_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R5361	001	0	1	31	11	R5361_001_0	3	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
R5361	001	0	1	31	11	R5361_001_0	3	2		01	11a;		2		1	15	15	2			2	
R5361	001	0	1	31	11	R5361_001_0	3	3		01	12;		2		1	20	20	2			2	
R5361	001	0	1	31	11	R5361_001_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
R5361	001	0	1	31	11	R5361_001_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13c;14b;14c;16a;	2		1	50	50	2			2	
R5361	001	0	1	31	11	R5361_001_0	3	6		10		13b;	1	15.00	1	50	50	2			2	
R5361	001	0	1	31	11	R5361_001_0	3	7		01	14a;		2		1	50	50	1	0.00	0.00	2	
R5361	002	0	1	31	11	R5361_002_0	3	1		11	9d;14a;14d;14e;	9d;14b;18b;	2		2			1	0.00	0.00	2	
R5361	002	0	1	31	11	R5361_002_0	3	2		01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;8b1;8b2;8b3;9a;9b;9c;10a;11a;11b;11c;12;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R5361	002	0	1	31	11	R5361_002_0	3	3		01	8a1;		2		1	20	20	1	0.00	0.00	2	
R5361	002	0	1	31	11	R5361_002_0	3	4		10		13c;14c;18a;	2		1	50	50	2			2	
R5361	002	0	1	31	11	R5361_002_0	3	5		10		13b;	1	15.00	1	50	50	2			2	
R5361	801	0	1	31	11	R5361_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
R5361	801	0	1	31	11	R5361_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R5361	802	0	1	31	11	R5361_802_0	2	1		01	6;14a;		2		1	0	0	2			2	
R5361	802	0	1	31	11	R5361_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R5361	803	0	1	31	11	R5361_803_0	2	1		01	6;14a;		2		1	0	0	2			2	
R5361	803	0	1	31	11	R5361_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R5495	001	0	1	31	11	R5495_001_0	3	1		11	9d;17b;	9d;17a;17b;18a;	2		2			1	0.00	0.00	2	
R5495	001	0	1	31	11	R5495_001_0	3	2		10		18b;	2		2			1	699.00	999.00	2	
R5495	001	0	1	31	11	R5495_001_0	3	3		01	6;11a;11b;11c;12;		2		1	20	20	2			2	
R5495	001	0	1	31	11	R5495_001_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
R5495	001	0	1	31	11	R5495_001_0	3	5		01	8a1;15;		2		1	20	30	2			2	
R5495	001	0	1	31	11	R5495_001_0	3	6		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	14b;	2		1	30	30	2			2	
R5495	001	0	1	31	11	R5495_001_0	3	7		01	14a;		2		1	30	30	1	0.00	0.00	2	
R5495	001	0	1	31	11	R5495_001_0	3	8		10		13c;14c;16a;16b;	2		1	50	50	2			2	
R5495	001	0	1	31	11	R5495_001_0	3	9		10		13b;	1	30.00	1	50	50	2			2	
R5495	002	0	1	31	11	R5495_002_0	2	1		11	9d;17b;	9d;	2		2			1	0.00	0.00	2	
R5495	002	0	1	31	11	R5495_002_0	2	2		01	8b2;11a;12;		2		1	20	20	2			2	
R5495	002	0	1	31	11	R5495_002_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
R5495	002	0	1	31	11	R5495_002_0	2	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	14b;	2		1	30	30	2			2	
R5495	002	0	1	31	11	R5495_002_0	2	5		01	14a;		2		1	30	30	1	0.00	0.00	2	
R5495	002	0	1	31	11	R5495_002_0	2	6		10		14c;	2		1	50	50	2			2	
R5495	002	0	1	31	11	R5495_002_0	2	7		10		13b;	1	30.00	1	50	50	2			2	
R5495	801	0	1	31	11	R5495_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
R5495	801	0	1	31	11	R5495_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R5495	802	0	1	31	11	R5495_802_0	2	1		01	6;14a;		2		1	0	0	2			2	
R5495	802	0	1	31	11	R5495_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R5495	803	0	1	31	11	R5495_803_0	2	1		01	6;14a;		2		1	0	0	2			2	
R5495	803	0	1	31	11	R5495_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R5826	005	0	1	31	11	R5826_005_0	2	1		11	9d;17b;	9d;17a;	2		2			1	0.00	0.00	2	
R5826	005	0	1	31	11	R5826_005_0	2	10		01	8b1;		2		1	40	40	1	45.00	175.00	2	
R5826	005	0	1	31	11	R5826_005_0	2	11		01	3-1;3-2;3-3;7c;7i;8a1;8a2;8b2;8b3;9c;14e;		2		1	40	40	1	45.00	45.00	2	
R5826	005	0	1	31	11	R5826_005_0	2	12		10		14c;16a;16b;	2		1	50	50	2			2	
R5826	005	0	1	31	11	R5826_005_0	2	13		10		13b;	1	50.00	1	50	50	2			2	
R5826	005	0	1	31	11	R5826_005_0	2	2		11	7a;7b;7d;7e;7f;7g;7h;14d;16b;17a;18a;	14b;	2		2			1	45.00	45.00	2	
R5826	005	0	1	31	11	R5826_005_0	2	3		01	12;		2		1	20	20	2			2	
R5826	005	0	1	31	11	R5826_005_0	2	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
R5826	005	0	1	31	11	R5826_005_0	2	5		01	15;		2		1	20	40	2			2	
R5826	005	0	1	31	11	R5826_005_0	2	6		01	11b;		2		1	25	25	2			2	
R5826	005	0	1	31	11	R5826_005_0	2	7		01	11a;		2		1	30	30	2			2	
R5826	005	0	1	31	11	R5826_005_0	2	8		01	5;6;9a;9b;11c;		2		1	40	40	2			2	
R5826	005	0	1	31	11	R5826_005_0	2	9		01	14a;		2		1	40	40	1	0.00	45.00	2	
R5826	018	0	1	31	11	R5826_018_0	3	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
R5826	018	0	1	31	11	R5826_018_0	3	10		01	8b1;		2		1	30	30	1	45.00	75.00	2	
R5826	018	0	1	31	11	R5826_018_0	3	11		10		13c;16a;16b;	2		1	50	50	2			2	
R5826	018	0	1	31	11	R5826_018_0	3	12		10		13b;	1	10.00	1	50	50	2			2	
R5826	018	0	1	31	11	R5826_018_0	3	13		10		14c;	1	500.00	1	50	50	1	0.00	0.00	2	
R5826	018	0	1	31	11	R5826_018_0	3	2		11	7a;7b;7d;7e;7f;7g;7h;14d;16b;17a;18a;	14b;	2		2			1	45.00	45.00	2	
R5826	018	0	1	31	11	R5826_018_0	3	3		01	11a;11b;12;		2		1	20	20	2			2	
R5826	018	0	1	31	11	R5826_018_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
R5826	018	0	1	31	11	R5826_018_0	3	5		01	15;		2		1	20	30	2			2	
R5826	018	0	1	31	11	R5826_018_0	3	6		10		18a;18b;	2		1	25	25	2			2	
R5826	018	0	1	31	11	R5826_018_0	3	7		01	5;6;9a;9b;11c;		2		1	30	30	2			2	
R5826	018	0	1	31	11	R5826_018_0	3	8		01	14a;		2		1	30	30	1	0.00	45.00	2	
R5826	018	0	1	31	11	R5826_018_0	3	9		01	3-1;3-2;3-3;7c;7i;8a1;8a2;8b2;8b3;9c;14e;		2		1	30	30	1	45.00	45.00	2	
R5826	074	0	1	31	11	R5826_074_0	3	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
R5826	074	0	1	31	11	R5826_074_0	3	10		01	8b1;		2		1	50	50	1	60.00	275.00	2	
R5826	074	0	1	31	11	R5826_074_0	3	11		01	3-1;3-2;3-3;7c;7i;8a1;8a2;8b2;8b3;9c;		2		1	50	50	1	60.00	60.00	2	
R5826	074	0	1	31	11	R5826_074_0	3	2		01	7a;7b;7d;7e;7f;7g;7h;16b;17a;18a;		2		2			1	60.00	60.00	2	
R5826	074	0	1	31	11	R5826_074_0	3	3		01	12;		2		1	20	20	2			2	
R5826	074	0	1	31	11	R5826_074_0	3	4		01	10a;		2		1	20	20	1	265.00	265.00	2	
R5826	074	0	1	31	11	R5826_074_0	3	5		01	15;		2		1	20	50	2			2	
R5826	074	0	1	31	11	R5826_074_0	3	6		01	11b;		2		1	25	25	2			2	
R5826	074	0	1	31	11	R5826_074_0	3	7		01	11a;		2		1	30	30	2			2	
R5826	074	0	1	31	11	R5826_074_0	3	8		11	5;6;9a;9b;11c;14d;14e;	14b;14c;	2		1	50	50	2			2	
R5826	074	0	1	31	11	R5826_074_0	3	9		01	14a;		2		1	50	50	1	0.00	0.00	2	
R5826	805	0	1	31	11	R5826_805_0	2	1		01	6;14a;		2		1	0	0	2			2	
R5826	805	0	1	31	11	R5826_805_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R5826	819	0	1	31	11	R5826_819_0	2	1		01	6;14a;		2		1	0	0	2			2	
R5826	819	0	1	31	11	R5826_819_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R5826	834	0	1	31	11	R5826_834_0	2	1		01	6;14a;		2		1	0	0	2			2	
R5826	834	0	1	31	11	R5826_834_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R5941	013	0	1	31	11	R5941_013_0	5	1	$0	11	9d;16b;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
R5941	013	0	1	31	11	R5941_013_0	5	2	20%	11	8b2;12;	16a;18a;	2		1	20	20	2			2	
R5941	013	0	1	31	11	R5941_013_0	5	3	Ambulance	01	10a;		2		1	20	20	1	295.00	295.00	2	
R5941	013	0	1	31	11	R5941_013_0	5	4	Diag/Rad	01	8a1;8a2;8b1;8b3;		2		1	30	30	2			2	
R5941	013	0	1	31	11	R5941_013_0	5	5	PCP	01	7a;7g;		2		2			1	25.00	25.00	2	
R5941	013	0	1	31	11	R5941_013_0	5	6	Specialist	11	7b;7c;7d;7e;7f;7h;7i;	7f;14b;	2		2			1	50.00	50.00	2	
R5941	013	0	1	31	11	R5941_013_0	5	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;		2		1	40	40	2			2	
R5941	013	0	1	31	11	R5941_013_0	5	8	$0	10		14c;	1	95.00	2			1	0.00	0.00	2	
R5941	013	0	1	31	11	R5941_013_0	5	9	50%	10		18b;	2		1	50	50	2			2	
R5941	014	0	1	31	11	R5941_014_0	3	1	$0	11	9d;16b;17b;	9d;17a;	2		2			1	0.00	0.00	2	
R5941	014	0	1	31	11	R5941_014_0	3	2	20%	11	8b2;12;	16a;18a;	2		1	20	20	2			2	
R5941	014	0	1	31	11	R5941_014_0	3	3	Ambulance	01	10a;		2		1	20	20	1	295.00	295.00	2	
R5941	014	0	1	31	11	R5941_014_0	3	4	Diag/Rad	01	8a1;8a2;8b1;8b3;		2		1	30	30	2			2	
R5941	014	0	1	31	11	R5941_014_0	3	5	PCP	01	7a;7g;		2		2			1	40.00	40.00	2	
R5941	014	0	1	31	11	R5941_014_0	3	6	Specialist	11	7b;7c;7d;7e;7f;7h;7i;	7f;14b;	2		2			1	60.00	60.00	2	
R5941	014	0	1	31	11	R5941_014_0	3	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;		2		1	40	40	2			2	
R5941	014	0	1	31	11	R5941_014_0	3	8	$0	10		14c;	1	95.00	2			1	0.00	0.00	2	
R5941	014	0	1	31	11	R5941_014_0	3	9	50%	10		18b;	2		1	50	50	2			2	
R5941	015	0	1	31	11	R5941_015_0	3	1	$0	11	9d;16b;17b;	9d;17a;	2		2			1	0.00	0.00	2	
R5941	015	0	1	31	11	R5941_015_0	3	10	50%	10		18b;	2		1	50	50	2			2	
R5941	015	0	1	31	11	R5941_015_0	3	2	20%	11	8a2;8b2;12;15;	16a;18a;	2		1	20	20	2			2	
R5941	015	0	1	31	11	R5941_015_0	3	3	Ambulance	01	10a;		2		1	20	20	1	295.00	295.00	2	
R5941	015	0	1	31	11	R5941_015_0	3	4	Diag/Rad	01	8a1;8b1;8b3;		2		1	35	35	2			2	
R5941	015	0	1	31	11	R5941_015_0	3	5	PCP	01	7a;7g;		2		2			1	40.00	40.00	2	
R5941	015	0	1	31	11	R5941_015_0	3	6	Specialist	11	7b;7c;7d;7e;7f;7h;7i;	7f;14b;	2		2			1	60.00	60.00	2	
R5941	015	0	1	31	11	R5941_015_0	3	7	General	01	3-1;3-2;3-3;5;6;9c;11a;11c;14a;14d;14e;		2		1	40	40	2			2	
R5941	015	0	1	31	11	R5941_015_0	3	8	$0	10		14c;	1	95.00	2			1	0.00	0.00	2	
R5941	015	0	1	31	11	R5941_015_0	3	9	40%	01	9a;9b;11b;17a;18a;		2		1	40	40	2			2	
R6694	003	0	1	31	11	R6694_003_0	4	1	20% OON Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		1	20	20	2			2	
R6694	003	0	1	31	11	R6694_003_0	4	2	Ambulance	01	10a;		2		2			1	150.00	150.00	2	
R6694	003	0	1	31	11	R6694_003_0	4	3	Dental	10		16a;	2		2			1	0.00	0.00	2	
R6694	003	0	1	31	11	R6694_003_0	4	4	Eyewear Allowance	10		17b;	2		2			1	0.00	0.00	2	
R6694	003	0	1	31	11	R6694_003_0	4	5	Hearing Aid Allowance	10		18b;	2		2			1	0.00	0.00	2	
R6694	003	0	1	31	11	R6694_003_0	4	6	$0	11	14d;	14c;	2		2			1	0.00	0.00	2	
R6694	003	0	1	31	11	R6694_003_0	4	7	Preventive 0% - 20%	01	11c;14a;		2		1	0	20	2			2	
R6694	005	0	1	31	11	R6694_005_0	3	1	20% OON Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;12;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	20	20	2			2	
R6694	005	0	1	31	11	R6694_005_0	3	2	Ambulance	01	10a;		2		2			1	150.00	150.00	2	
R6694	005	0	1	31	11	R6694_005_0	3	3	Med Prev 0% - 20%	01	11c;14a;		2		1	0	20	2			2	
R6694	005	0	1	31	11	R6694_005_0	3	4	$0	11	14d;	14c;16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
R6694	006	0	1	31	11	R6694_006_0	4	1	50% OON Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		1	50	50	2			2	
R6694	006	0	1	31	11	R6694_006_0	4	2	Ambulance	01	10a;		2		2			1	200.00	200.00	2	
R6694	006	0	1	31	11	R6694_006_0	4	3	20%	01	12;		2		1	20	20	2			2	
R6694	006	0	1	31	11	R6694_006_0	4	4	$0 Copayment OON	10		14c;	2		2			1	0.00	0.00	2	
R6694	006	0	1	31	11	R6694_006_0	4	5	0-50%	01	14a;		2		1	0	50	2			2	
R6694	006	0	1	31	11	R6694_006_0	4	6	0% OON	01	14d;		2		1	0	0	2			2	
R6694	006	0	1	31	11	R6694_006_0	4	7	0-20%	01	11c;		2		1	0	20	2			2	
R6801	008	0	1	31	11	R6801_008_0	4	1	Group 1	11	7e;7h;8a1;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;12;15;17b;	9d;	2		1	20	20	2			2	
R6801	008	0	1	31	11	R6801_008_0	4	2	Group 2	11	6;7a;8a2;14a;14d;18a;	7f;10b;14c;16a;16b;17a;17b;18a;18b;	2		2			1	0.00	0.00	2	
R6801	008	0	1	31	11	R6801_008_0	4	3	Group 3	01	14e;		2		1	20	20	1	0.00	0.00	2	
R6801	008	0	1	31	11	R6801_008_0	4	4	Group 4	10		13b;	1	160.00	2			1	0.00	0.00	2	
R6801	008	0	1	31	11	R6801_008_0	4	5	Group 5	01	11c;		2		1	20	30	2			2	
R6801	008	0	1	31	11	R6801_008_0	4	6	Group 6	01	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;		2		1	19	19	2			2	
R6801	008	0	1	31	11	R6801_008_0	4	7	Group 7	01	7g;		2		1	0	19	2			2	
R6801	008	0	1	31	11	R6801_008_0	4	8	Group 8	01	5;		2		2			1	55.00	55.00	2	
R6801	009	0	1	31	11	R6801_009_0	4	1	Group 1	01	7d;		2		2			1	45.00	45.00	2	
R6801	009	0	1	31	11	R6801_009_0	4	10	Group 10	01	10a;		2		2			1	250.00	250.00	2	
R6801	009	0	1	31	11	R6801_009_0	4	11	Group 11	11	7f;9d;14a;14d;14e;17b;	7f;9d;10b;14c;16a;16b;17b;	2		2			1	0.00	0.00	2	
R6801	009	0	1	31	11	R6801_009_0	4	12	Group 12	01	8b3;		2		2			1	14.00	14.00	2	
R6801	009	0	1	31	11	R6801_009_0	4	13	Group 13	11	3-1;3-2;3-3;7b;17a;	17a;	2		2			1	20.00	20.00	2	
R6801	009	0	1	31	11	R6801_009_0	4	14	Group 14	01	8a2;		2		2			1	10.00	10.00	2	
R6801	009	0	1	31	11	R6801_009_0	4	2	Group 2	01	5;		2		2			1	55.00	55.00	2	
R6801	009	0	1	31	11	R6801_009_0	4	3	Group 3	01	6;11a;		2		1	50	50	2			2	
R6801	009	0	1	31	11	R6801_009_0	4	4	Group 4	11	7a;18a;	18a;	2		2			1	15.00	15.00	2	
R6801	009	0	1	31	11	R6801_009_0	4	5	Group 5	01	7g;		2		2			1	15.00	45.00	2	
R6801	009	0	1	31	11	R6801_009_0	4	6	Group 6	01	7e;7h;9c;		2		2			1	30.00	40.00	2	
R6801	009	0	1	31	11	R6801_009_0	4	7	Group 7	10		18b;	2		2			1	330.00	380.00	2	
R6801	009	0	1	31	11	R6801_009_0	4	8	Group 8	01	8a1;8b1;8b2;9a;9b;11b;11c;12;15;16b;		2		1	20	20	2			2	
R6801	009	0	1	31	11	R6801_009_0	4	9	Group 9	01	7c;7i;		2		2			1	40.00	40.00	2	
R6801	011	0	1	31	11	R6801_011_0	4	1	Group 1	11	8a1;8b1;8b2;8b3;9a;9b;9d;10a;11a;11b;12;15;	9d;	2		1	20	20	2			2	
R6801	011	0	1	31	11	R6801_011_0	4	2	Group 2	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;9c;14a;14d;16b;17a;17b;18a;	7f;10b;14c;17a;18a;18b;	2		2			1	0.00	0.00	2	
R6801	011	0	1	31	11	R6801_011_0	4	3	Group 3	10		13b;	1	275.00	2			1	0.00	0.00	2	
R6801	011	0	1	31	11	R6801_011_0	4	4	Group  4	01	14e;		2		1	20	20	1	0.00	0.00	2	
R6801	011	0	1	31	11	R6801_011_0	4	5	Group 5	01	11c;		2		1	20	30	2			2	
R6801	011	0	1	31	11	R6801_011_0	4	6	Group 6	01	5;		2		2			1	55.00	55.00	2	
R6801	012	0	1	31	11	R6801_012_0	4	1	Group 1	11	7d;7f;	7f;	2		2			1	45.00	45.00	2	
R6801	012	0	1	31	11	R6801_012_0	4	10	Group 10	01	7g;		2		2			1	15.00	45.00	2	
R6801	012	0	1	31	11	R6801_012_0	4	11	Group 11	11	9d;14a;14d;14e;17b;	9d;14b;14c;16b;17b;	2		2			1	0.00	0.00	2	
R6801	012	0	1	31	11	R6801_012_0	4	12	Group 12	10		18b;	2		2			1	330.00	380.00	2	
R6801	012	0	1	31	11	R6801_012_0	4	13	Group 13	01	10a;		2		2			1	250.00	250.00	2	
R6801	012	0	1	31	11	R6801_012_0	4	14	Group 14	01	7c;7i;		2		2			1	40.00	40.00	2	
R6801	012	0	1	31	11	R6801_012_0	4	15	Group 15	01	8a2;		2		2			1	10.00	10.00	2	
R6801	012	0	1	31	11	R6801_012_0	4	2	Group 2	01	6;		2		1	50	50	2			2	
R6801	012	0	1	31	11	R6801_012_0	4	3	Group 3	01	5;		2		2			1	55.00	55.00	2	
R6801	012	0	1	31	11	R6801_012_0	4	4	Group 4	11	3-1;3-2;3-3;7b;17a;	16a;17a;	2		2			1	20.00	20.00	2	
R6801	012	0	1	31	11	R6801_012_0	4	5	Group 5	11	7a;18a;	18a;	2		2			1	15.00	15.00	2	
R6801	012	0	1	31	11	R6801_012_0	4	6	Group 6	01	7e;7h;9c;		2		2			1	30.00	40.00	2	
R6801	012	0	1	31	11	R6801_012_0	4	7	Group 7	01	8b3;		2		2			1	14.00	14.00	2	
R6801	012	0	1	31	11	R6801_012_0	4	8	Group 8	01	8a1;8b1;8b2;9a;9b;11b;11c;12;15;16b;		2		1	20	20	2			2	
R6801	012	0	1	31	11	R6801_012_0	4	9	Group 9	01	11a;		2		1	40	40	2			2	
R7220	001	0	1	31	11	R7220_001_0	2	1		11	9d;	9d;17a;	2		2			1	0.00	0.00	2	
R7220	001	0	1	31	11	R7220_001_0	2	2		01	12;		2		1	20	20	2			2	
R7220	001	0	1	31	11	R7220_001_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
R7220	001	0	1	31	11	R7220_001_0	2	4		01	11a;11b;11c;		2		1	35	35	2			2	
R7220	001	0	1	31	11	R7220_001_0	2	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;15;16b;17a;17b;18a;	13c;14b;14c;	2		1	50	50	2			2	
R7220	001	0	1	31	11	R7220_001_0	2	6		10		13b;	1	50.00	1	50	50	2			2	
R7220	001	0	1	31	11	R7220_001_0	2	7		01	14a;		2		1	50	50	1	0.00	0.00	2	
R7220	002	0	1	31	11	R7220_002_0	2	1		11	9d;	9d;17a;	2		2			1	0.00	0.00	2	
R7220	002	0	1	31	11	R7220_002_0	2	2		01	12;		2		1	20	20	2			2	
R7220	002	0	1	31	11	R7220_002_0	2	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
R7220	002	0	1	31	11	R7220_002_0	2	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;14b;14c;	2		1	50	50	2			2	
R7220	002	0	1	31	11	R7220_002_0	2	5		10		13b;	1	50.00	1	50	50	2			2	
R7220	002	0	1	31	11	R7220_002_0	2	6		01	14a;		2		1	50	50	1	0.00	0.00	2	
R7220	801	0	1	31	11	R7220_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
R7220	801	0	1	31	11	R7220_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R7220	802	0	1	31	11	R7220_802_0	3	1		01	6;14a;		2		1	0	0	2			2	
R7220	802	0	1	31	11	R7220_802_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R7220	803	0	1	31	11	R7220_803_0	2	1		01	6;14a;		2		1	0	0	2			2	
R7220	803	0	1	31	11	R7220_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R7315	001	0	1	31	11	R7315_001_0	3	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
R7315	001	0	1	31	11	R7315_001_0	3	2		01	11a;12;		2		1	20	20	2			2	
R7315	001	0	1	31	11	R7315_001_0	3	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
R7315	001	0	1	31	11	R7315_001_0	3	4		01	15;		2		1	20	30	2			2	
R7315	001	0	1	31	11	R7315_001_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	14b;	2		1	30	30	2			2	
R7315	001	0	1	31	11	R7315_001_0	3	6		01	14a;		2		1	30	30	1	0.00	0.00	2	
R7315	001	0	1	31	11	R7315_001_0	3	7		10		13c;14c;16a;16b;	2		1	50	50	2			2	
R7315	001	0	1	31	11	R7315_001_0	3	8		10		13b;	1	25.00	1	50	50	2			2	
R7315	002	0	1	31	11	R7315_002_0	3	1		11	9d;17b;	9d;17a;17b;	2		2			1	0.00	0.00	2	
R7315	002	0	1	31	11	R7315_002_0	3	2		01	11a;11c;12;		2		1	20	20	2			2	
R7315	002	0	1	31	11	R7315_002_0	3	3		01	10a;		2		1	20	20	1	265.00	265.00	2	
R7315	002	0	1	31	11	R7315_002_0	3	4		01	15;		2		1	20	40	2			2	
R7315	002	0	1	31	11	R7315_002_0	3	5		01	11b;		2		1	25	25	2			2	
R7315	002	0	1	31	11	R7315_002_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	14b;	2		1	40	40	2			2	
R7315	002	0	1	31	11	R7315_002_0	3	7		01	14a;		2		1	40	40	1	0.00	0.00	2	
R7315	002	0	1	31	11	R7315_002_0	3	8		10		13c;14c;	2		1	50	50	2			2	
R7315	002	0	1	31	11	R7315_002_0	3	9		10		13b;	1	30.00	1	50	50	2			2	
R7315	801	0	1	31	11	R7315_801_0	2	1		01	6;14a;		2		1	0	0	2			2	
R7315	801	0	1	31	11	R7315_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R7315	802	0	1	31	11	R7315_802_0	2	1		01	6;14a;		2		1	0	0	2			2	
R7315	802	0	1	31	11	R7315_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R7315	803	0	1	31	11	R7315_803_0	2	1		01	6;14a;		2		1	0	0	2			2	
R7315	803	0	1	31	11	R7315_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		1	20	20	2			2	
R7444	001	0	1	31	11	R7444_001_0	3	1	Group 1	11	3-1;3-2;3-3;7a;8a1;8b1;8b2;8b3;9a;9b;11b;11c;14d;15;16b;	14b;	2		1	30	30	2			2	
R7444	001	0	1	31	11	R7444_001_0	3	10	Group 10	10		18b;	2		2			1	330.00	380.00	2	
R7444	001	0	1	31	11	R7444_001_0	3	11	Group 11	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	50.00	50.00	2	
R7444	001	0	1	31	11	R7444_001_0	3	12	Group 12	01	8a2;		2		2			1	10.00	10.00	2	
R7444	001	0	1	31	11	R7444_001_0	3	13		01	7g;		2		1	30	30	1	50.00	50.00	2	
R7444	001	0	1	31	11	R7444_001_0	3	2	Group 2	11	9d;17b;	9d;14c;17b;	2		2			1	0.00	0.00	2	
R7444	001	0	1	31	11	R7444_001_0	3	3	Group 3	01	6;11a;		2		1	50	50	2			2	
R7444	001	0	1	31	11	R7444_001_0	3	4	Group 4	01	12;		2		1	20	20	2			2	
R7444	001	0	1	31	11	R7444_001_0	3	5	Group 5	01	14a;		2		1	0	30	2			2	
R7444	001	0	1	31	11	R7444_001_0	3	6	Group 6	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
R7444	001	0	1	31	11	R7444_001_0	3	7	Group 7	01	5;		2		2			1	75.00	75.00	2	
R7444	001	0	1	31	11	R7444_001_0	3	8	Group 8	01	10a;		2		2			1	250.00	250.00	2	
R7444	001	0	1	31	11	R7444_001_0	3	9	Group 9	01	14e;		2		1	30	30	1	50.00	50.00	2	
R7444	003	0	1	31	11	R7444_003_0	3	1	Group 1	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	70.00	70.00	2	
R7444	003	0	1	31	11	R7444_003_0	3	10	Group 10	01	6;11a;15;		2		1	50	50	2			2	
R7444	003	0	1	31	11	R7444_003_0	3	11	Group 11	01	14a;		2		1	0	40	2			2	
R7444	003	0	1	31	11	R7444_003_0	3	12	Group 12	01	7a;		2		2			1	45.00	45.00	2	
R7444	003	0	1	31	11	R7444_003_0	3	13	Group 13	01	7g;		2		2			1	45.00	70.00	2	
R7444	003	0	1	31	11	R7444_003_0	3	14	Group 14	01	8b3;		2		2			1	21.00	21.00	2	
R7444	003	0	1	31	11	R7444_003_0	3	15	Group 15	01	8a2;		2		2			1	2.00	2.00	2	
R7444	003	0	1	31	11	R7444_003_0	3	2	Group 2	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;11b;11c;14d;16b;17b;	14b;	2		1	40	40	2			2	
R7444	003	0	1	31	11	R7444_003_0	3	3	Group 3	01	14e;		2		1	40	40	1	70.00	70.00	2	
R7444	003	0	1	31	11	R7444_003_0	3	4	Group 4	10		18b;	2		2			1	330.00	380.00	2	
R7444	003	0	1	31	11	R7444_003_0	3	5	Group 5	01	5;		2		2			1	75.00	75.00	2	
R7444	003	0	1	31	11	R7444_003_0	3	6	Group 6	01	10a;		2		2			1	250.00	250.00	2	
R7444	003	0	1	31	11	R7444_003_0	3	7	Group 7	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
R7444	003	0	1	31	11	R7444_003_0	3	8	Group 8	01	12;		2		1	20	20	2			2	
R7444	003	0	1	31	11	R7444_003_0	3	9	Group 9	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
R7444	004	0	1	31	11	R7444_004_0	3	1	Group 1	11	7b;7c;7d;7f;7i;17a;18a;	7f;17a;18a;	2		2			1	70.00	70.00	2	
R7444	004	0	1	31	11	R7444_004_0	3	10	Group 10	01	6;11a;15;		2		1	50	50	2			2	
R7444	004	0	1	31	11	R7444_004_0	3	11	Group 11	01	14a;		2		1	0	40	2			2	
R7444	004	0	1	31	11	R7444_004_0	3	12	Group 12	01	7a;		2		2			1	45.00	45.00	2	
R7444	004	0	1	31	11	R7444_004_0	3	13	Group 13	01	7g;		2		2			1	45.00	70.00	2	
R7444	004	0	1	31	11	R7444_004_0	3	14	Group 14	01	8b3;		2		2			1	21.00	21.00	2	
R7444	004	0	1	31	11	R7444_004_0	3	15	Group 15	01	8a2;		2		2			1	10.00	10.00	2	
R7444	004	0	1	31	11	R7444_004_0	3	2	Group 2	11	3-1;3-2;3-3;8a1;8b1;8b2;9a;9b;11b;11c;14d;16b;17b;	14b;	2		1	40	40	2			2	
R7444	004	0	1	31	11	R7444_004_0	3	3	Group 3	01	14e;		2		1	40	40	1	70.00	70.00	2	
R7444	004	0	1	31	11	R7444_004_0	3	4	Group 4	10		18b;	2		2			1	330.00	380.00	2	
R7444	004	0	1	31	11	R7444_004_0	3	5	Group 5	01	5;		2		2			1	75.00	75.00	2	
R7444	004	0	1	31	11	R7444_004_0	3	6	Group 6	01	10a;		2		2			1	250.00	250.00	2	
R7444	004	0	1	31	11	R7444_004_0	3	7	Group 7	01	7e;7h;9c;		2		2			1	35.00	45.00	2	
R7444	004	0	1	31	11	R7444_004_0	3	8	Group 8	01	12;		2		1	20	20	2			2	
R7444	004	0	1	31	11	R7444_004_0	3	9	Group 9	11	9d;	9d;14c;	2		2			1	0.00	0.00	2	
R7444	008	0	1	31	11	R7444_008_0	3	1	Group 1	11	7d;7f;	7f;	2		2			1	45.00	45.00	2	
R7444	008	0	1	31	11	R7444_008_0	3	10	Group 10	01	5;		2		2			1	55.00	55.00	2	
R7444	008	0	1	31	11	R7444_008_0	3	11	Group 11	11	9d;14a;14d;14e;17a;17b;	9d;14b;14c;16b;17a;17b;	2		2			1	0.00	0.00	2	
R7444	008	0	1	31	11	R7444_008_0	3	12	Group 12	01	10a;		2		2			1	250.00	250.00	2	
R7444	008	0	1	31	11	R7444_008_0	3	13	Group 13	10		18b;	2		2			1	330.00	380.00	2	
R7444	008	0	1	31	11	R7444_008_0	3	14	Group 14	01	7g;		2		2			1	20.00	45.00	2	
R7444	008	0	1	31	11	R7444_008_0	3	2	Group 2	01	7e;7h;9c;		2		2			1	30.00	40.00	2	
R7444	008	0	1	31	11	R7444_008_0	3	3	Group 3	01	6;		2		1	50	50	2			2	
R7444	008	0	1	31	11	R7444_008_0	3	4	Group 4	11	3-1;3-2;3-3;7a;7b;18a;	16a;18a;	2		2			1	20.00	20.00	2	
R7444	008	0	1	31	11	R7444_008_0	3	5	Group 5	01	8a2;		2		2			1	10.00	10.00	2	
R7444	008	0	1	31	11	R7444_008_0	3	6	Group 6	01	11a;		2		1	45	45	2			2	
R7444	008	0	1	31	11	R7444_008_0	3	7	Group 7	01	7c;7i;		2		2			1	40.00	40.00	2	
R7444	008	0	1	31	11	R7444_008_0	3	8	Group 8	01	8a1;8b1;8b2;9a;9b;11b;11c;12;15;16b;		2		1	20	20	2			2	
R7444	008	0	1	31	11	R7444_008_0	3	9	Group 9	01	8b3;		2		2			1	14.00	14.00	2	
R7444	009	0	1	31	11	R7444_009_0	3	1	Group 1	11	7e;7h;8a1;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;12;15;16b;17b;	9d;	2		1	20	20	2			2	
R7444	009	0	1	31	11	R7444_009_0	3	2	Group 2	11	6;7a;8a2;14a;14d;17a;18a;	7f;10b;14c;16a;16b;17a;17b;18a;18b;	2		2			1	0.00	0.00	2	
R7444	009	0	1	31	11	R7444_009_0	3	3	Group 3	01	11c;		2		1	20	30	2			2	
R7444	009	0	1	31	11	R7444_009_0	3	4	Group 4	10		13b;	1	170.00	2			1	0.00	0.00	2	
R7444	009	0	1	31	11	R7444_009_0	3	5	Group 5	01	14e;		2		1	20	20	1	0.00	0.00	2	
R7444	009	0	1	31	11	R7444_009_0	3	6	Group 6	01	3-1;3-2;3-3;7b;7c;7d;7f;7i;		2		1	19	19	2			2	
R7444	009	0	1	31	11	R7444_009_0	3	7	Group 7	01	7g;		2		1	0	19	2			2	
R7444	009	0	1	31	11	R7444_009_0	3	8	Group 8	01	5;		2		2			1	55.00	55.00	2	
R7444	010	0	1	31	11	R7444_010_0	3	1	Group 1	01	7d;		2		2			1	40.00	40.00	2	
R7444	010	0	1	31	11	R7444_010_0	3	10	Group 10	01	8a2;		2		2			1	10.00	10.00	2	
R7444	010	0	1	31	11	R7444_010_0	3	11	Group 11	11	7f;9d;14a;14d;14e;17a;17b;	7f;9d;10b;14c;16b;17a;17b;	2		2			1	0.00	0.00	2	
R7444	010	0	1	31	11	R7444_010_0	3	12	Group 12	01	10a;		2		2			1	250.00	250.00	2	
R7444	010	0	1	31	11	R7444_010_0	3	13	Group 13	10		18b;	2		2			1	330.00	380.00	2	
R7444	010	0	1	31	11	R7444_010_0	3	2	Group 2	01	5;		2		2			1	55.00	55.00	2	
R7444	010	0	1	31	11	R7444_010_0	3	3	Group 3	01	6;11a;		2		1	50	50	2			2	
R7444	010	0	1	31	11	R7444_010_0	3	4	Group 4	01	7c;7i;		2		2			1	40.00	40.00	2	
R7444	010	0	1	31	11	R7444_010_0	3	5	Group 5	11	3-1;3-2;3-3;7a;7b;18a;	16a;18a;	2		2			1	20.00	20.00	2	
R7444	010	0	1	31	11	R7444_010_0	3	6	Group 6	01	7e;7h;9c;		2		2			1	30.00	40.00	2	
R7444	010	0	1	31	11	R7444_010_0	3	7	Group 7	01	8b3;		2		2			1	14.00	14.00	2	
R7444	010	0	1	31	11	R7444_010_0	3	8	Group 8	01	8a1;8b1;8b2;9a;9b;11b;11c;12;15;16b;		2		1	20	20	2			2	
R7444	010	0	1	31	11	R7444_010_0	3	9	Group 9	01	7g;		2		2			1	20.00	40.00	2	
R7444	011	0	1	31	11	R7444_011_0	3	1	Group 1	11	8a1;8b1;8b2;8b3;9a;9b;9d;10a;11a;11b;12;15;	9d;	2		1	20	20	2			2	
R7444	011	0	1	31	11	R7444_011_0	3	2	Group 2	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;9c;14a;14d;16b;17a;17b;18a;	7f;10b;14c;16a;16b;17a;17b;18a;18b;	2		2			1	0.00	0.00	2	
R7444	011	0	1	31	11	R7444_011_0	3	3	Group 3	10		13b;	1	260.00	2			1	0.00	0.00	2	
R7444	011	0	1	31	11	R7444_011_0	3	4	Group  4	01	11c;		2		1	20	30	2			2	
R7444	011	0	1	31	11	R7444_011_0	3	5	Group 5	01	14e;		2		1	20	20	1	0.00	0.00	2	
R7444	011	0	1	31	11	R7444_011_0	3	6	Group 6	01	5;		2		2			1	55.00	55.00	2	
R7444	012	0	1	31	11	R7444_012_0	4	1	Group 1	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7b;7f;9d;13a;17a;18a;	2		1	40	40	2			2	
R7444	012	0	1	31	11	R7444_012_0	4	2	Group 2	01	14a;		2		1	0	40	2			2	
R7444	012	0	1	31	11	R7444_012_0	4	3	Group 3	01	10a;12;		2		1	20	20	2			2	
R7444	012	0	1	31	11	R7444_012_0	4	4	Group 4	11	6;8a2;17b;	13c;14c;16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
R7444	012	0	1	31	11	R7444_012_0	4	5	Group 5	10		13b;	1	205.00	2			1	0.00	0.00	2	
R7444	012	0	1	31	11	R7444_012_0	4	6	Group 6	10		10b;	2		1	75	75	2			2	
R7444	013	0	1	31	11	R7444_013_0	5	1	Group 1	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7b;7f;9d;13a;17a;18a;	2		1	40	40	2			2	
R7444	013	0	1	31	11	R7444_013_0	5	2	Group 2	01	14a;		2		1	0	40	2			2	
R7444	013	0	1	31	11	R7444_013_0	5	3	Group 3	01	10a;12;		2		1	20	20	2			2	
R7444	013	0	1	31	11	R7444_013_0	5	4	Group 4	11	6;8a2;17b;	13c;14c;16a;16b;17b;18b;	2		2			1	0.00	0.00	2	
R7444	013	0	1	31	11	R7444_013_0	5	5	Group 5	10		13b;	1	225.00	2			1	0.00	0.00	2	
R7444	013	0	1	31	11	R7444_013_0	5	6	Group 6	10		10b;	2		1	75	75	2			2	
