pbp_a_hnumber	pbp_a_plan_identifier	segment_id	pbp_a_ben_cov	pbp_a_plan_type	orgtype	bid_id	version	pbp_c_pos_outpt_group_num_id	pbp_c_pos_group_lbl	pbp_c_pos_oupt_bencat_bens	pbp_c_pos_outpt_mc_bencats	pbp_c_pos_outpt_nmc_bencats	pbp_c_pos_outpt_coins_yn	pbp_c_pos_outpt_coins_min_pct	pbp_c_pos_outpt_coins_max_pct	pbp_c_pos_outpt_copay_yn	pbp_c_pos_outpt_copay_min_amt	pbp_c_pos_outpt_copay_max_amt	pbp_c_pos_outpt_maxplan_yn	pbp_c_pos_outpt_maxplan_amt	pbp_c_pos_outpt_maxplan_per	pbp_c_pos_outpt_maxplan_per_d	pbp_c_pos_outpt_deduct_yn	pbp_c_pos_outpt_deduct_amt
H0028	015	0	1	02	01	H0028_015_0	7	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	5000.00	3		2	
H0028	016	0	1	02	01	H0028_016_0	8	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	1500.00	3		2	
H0028	054	1	1	02	01	H0028_054_1	7	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	1500.00	3		2	
H0028	054	2	1	02	01	H0028_054_2	6	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	1500.00	3		2	
H0028	055	0	1	02	01	H0028_055_0	6	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	1000.00	3		2	
H0028	056	0	1	02	01	H0028_056_0	8	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	1000.00	3		2	
H0169	001	0	1	02	01	H0169_001_0	6	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H0169	002	0	1	02	01	H0169_002_0	5	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H0169	003	0	1	02	01	H0169_003_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H0169	004	0	1	02	01	H0169_004_0	5	1	Group 1	01	5;7e;7h;9c;		1	40	40	2			2				2	
H0169	004	0	1	02	01	H0169_004_0	5	2	Group 2	01	10a1;10a2;		1	20	20	2			2				2	
H0169	004	0	1	02	01	H0169_004_0	5	3	Group 3	10		16a;16b;	2			1	0.00	0.00	2				2	
H0169	006	0	1	02	01	H0169_006_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0169	006	0	1	02	01	H0169_006_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H0169	008	0	1	02	01	H0169_008_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0169	008	0	1	02	01	H0169_008_0	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H0251	002	0	1	02	01	H0251_002_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H0251	004	0	1	02	01	H0251_004_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H0321	002	0	1	02	01	H0321_002_0	5	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H0321	004	0	1	02	01	H0321_004_0	9	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H0332	004	0	1	02	01	H0332_004_0	11	1	Group 1 - 20%	01	8a1;8b1;8b2;9a1;9a2;9b;15;17a;18a;		1	20	20	2			2				2	
H0332	004	0	1	02	01	H0332_004_0	11	2	Group 2 - 50%	01	3-1;3-2;3-3;3-4;5;6;7c;7g;7k;9d;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;		1	50	50	2			2				2	
H0332	004	0	1	02	01	H0332_004_0	11	3	Group 3 - Copays/Coins	01	7a;7b;7d;7e;7f;7h;7i;8a2;8b3;9c;10a1;		1	40	50	1	10.00	250.00	2				2	
H0332	011	0	1	02	01	H0332_011_0	10	1	Group 1 - 40%	01	3-1;3-2;3-3;3-4;5;6;7b;7c;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;17a;17b;18a;		1	40	40	2			2				2	
H0332	011	0	1	02	01	H0332_011_0	10	2	Group 2 - $225 Copay	01	10a1;10a2;		2			1	225.00	225.00	2				2	
H0332	011	0	1	02	01	H0332_011_0	10	3	Group 3 - Other Copays/Coins	01	7a;7d;		1	40	40	1	10.00	60.00	2				2	
H0422	001	0	1	02	01	H0422_001_0	7	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7a;7c;7d;7f;7g;7i;7k;8a1;8b1;8b2;8b3;9a1;9a2;9b;9d;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;	1	25	25	2			2				2	
H0422	001	0	1	02	01	H0422_001_0	7	2	Group 2	01	10a1;10a2;		2			1	300.00	300.00	2				2	
H0422	001	0	1	02	01	H0422_001_0	7	3	Group 3	01	7e;7h;8a2;9c;14a;		2			2			2				2	
H0422	001	0	1	02	01	H0422_001_0	7	4	Group 4	10		16a;16b;	1	0	70	2			1	2000.00	3		2	
H0422	001	0	1	02	01	H0422_001_0	7	5	Group 5	10		17b;	2			2			1	100.00	3		2	
H0422	001	0	1	02	01	H0422_001_0	7	6	Group 6	01	15;		1	0	25	1	35.00	35.00	2				2	
H0422	003	0	1	02	01	H0422_003_0	9	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7a;7c;7d;7f;7g;7i;7k;8a1;8b1;8b2;8b3;9a1;9a2;9b;9d;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;	1	25	25	2			2				2	
H0422	003	0	1	02	01	H0422_003_0	9	2	Group 2	01	10a1;10a2;		2			1	300.00	300.00	2				2	
H0422	003	0	1	02	01	H0422_003_0	9	3	Group 3	01	7e;7h;8a2;9c;14a;		2			2			2				2	
H0422	003	0	1	02	01	H0422_003_0	9	4	Group 4	10		16a;16b;	2			2			1	850.00	3		2	
H0422	003	0	1	02	01	H0422_003_0	9	5	Group 5	10		17b;	2			2			1	100.00	3		2	
H0422	003	0	1	02	01	H0422_003_0	9	6	Group 6	01	15;		1	0	25	1	35.00	35.00	2				2	
H0432	003	0	1	02	01	H0432_003_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0432	003	0	1	02	01	H0432_003_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0432	004	0	1	02	01	H0432_004_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0432	004	0	1	02	01	H0432_004_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H0432	009	0	1	02	01	H0432_009_0	5	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H0432	012	0	1	02	01	H0432_012_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0432	012	0	1	02	01	H0432_012_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H0432	013	0	1	02	01	H0432_013_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0432	013	0	1	02	01	H0432_013_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H0432	017	0	1	02	01	H0432_017_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0432	017	0	1	02	01	H0432_017_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0523	074	0	1	02	01	H0523_074_0	8	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H0523	076	0	1	02	01	H0523_076_0	7	1	$0.00 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H0523	077	0	1	02	01	H0523_077_0	7	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H0523	078	0	1	02	01	H0523_078_0	8	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H0523	079	0	1	02	01	H0523_079_0	7	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H0523	080	0	1	02	01	H0523_080_0	7	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H0543	013	0	1	02	01	H0543_013_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	013	0	1	02	01	H0543_013_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	019	0	1	02	01	H0543_019_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	019	0	1	02	01	H0543_019_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	022	0	1	02	01	H0543_022_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	022	0	1	02	01	H0543_022_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	028	0	1	02	01	H0543_028_0	8	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	028	0	1	02	01	H0543_028_0	8	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	035	0	1	02	01	H0543_035_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	036	0	1	02	01	H0543_036_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	060	0	1	02	01	H0543_060_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	060	0	1	02	01	H0543_060_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	086	0	1	02	01	H0543_086_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	086	0	1	02	01	H0543_086_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	089	0	1	02	01	H0543_089_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	121	0	1	02	01	H0543_121_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	140	0	1	02	01	H0543_140_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	140	0	1	02	01	H0543_140_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	145	0	1	02	01	H0543_145_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	146	0	1	02	01	H0543_146_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	146	0	1	02	01	H0543_146_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	147	0	1	02	01	H0543_147_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	151	0	1	02	01	H0543_151_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	151	0	1	02	01	H0543_151_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	152	0	1	02	01	H0543_152_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	164	0	1	02	01	H0543_164_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	164	0	1	02	01	H0543_164_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	165	0	1	02	01	H0543_165_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	165	0	1	02	01	H0543_165_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	166	0	1	02	01	H0543_166_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	166	0	1	02	01	H0543_166_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	167	0	1	02	01	H0543_167_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	167	0	1	02	01	H0543_167_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	168	0	1	02	01	H0543_168_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	168	0	1	02	01	H0543_168_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	169	0	1	02	01	H0543_169_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	169	0	1	02	01	H0543_169_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	170	0	1	02	01	H0543_170_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	170	0	1	02	01	H0543_170_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	176	0	1	02	01	H0543_176_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	176	0	1	02	01	H0543_176_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	188	0	1	02	01	H0543_188_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	188	0	1	02	01	H0543_188_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	189	0	1	02	01	H0543_189_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	189	0	1	02	01	H0543_189_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	191	0	1	02	01	H0543_191_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	191	0	1	02	01	H0543_191_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	193	0	1	02	01	H0543_193_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	193	0	1	02	01	H0543_193_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	195	0	1	02	01	H0543_195_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	196	0	1	02	01	H0543_196_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	196	0	1	02	01	H0543_196_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	204	0	1	02	01	H0543_204_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	204	0	1	02	01	H0543_204_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	209	0	1	02	01	H0543_209_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	209	0	1	02	01	H0543_209_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	210	0	1	02	01	H0543_210_0	8	1	Group 1	01	7b;7d;7f;7g;8a1;17a;18a;		2			1	40.00	40.00	2				2	
H0543	210	0	1	02	01	H0543_210_0	8	2	Group 2	01	7e;7h;9c;		2			1	30.00	40.00	2				2	
H0543	210	0	1	02	01	H0543_210_0	8	3	Group 3	11	8a2;	16a;	2			1	0.00	0.00	2				2	
H0543	210	0	1	02	01	H0543_210_0	8	4	Group 4	01	9a1;9a2;9b;		2			1	500.00	500.00	2				2	
H0543	210	0	1	02	01	H0543_210_0	8	5	Group 5	01	15;		1	0	40	2			2				2	
H0543	210	0	1	02	01	H0543_210_0	8	6	Group 6	01	8b1;		2			1	200.00	200.00	2				2	
H0543	210	0	1	02	01	H0543_210_0	8	7	Group 7	01	8b2;		2			1	150.00	150.00	2				2	
H0543	210	0	1	02	01	H0543_210_0	8	8	Group 8	01	8b3;		2			1	20.00	20.00	2				2	
H0543	210	0	1	02	01	H0543_210_0	8	9	Group 9	10		16b;	1	0	50	2			2				2	
H0543	214	0	1	02	01	H0543_214_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	214	0	1	02	01	H0543_214_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	215	0	1	02	01	H0543_215_0	7	1	Group 1	01	7b;7d;7f;7g;8a1;17a;18a;		2			1	40.00	40.00	2				2	
H0543	215	0	1	02	01	H0543_215_0	7	2	Group 2	01	7e;7h;9c;		2			1	30.00	40.00	2				2	
H0543	215	0	1	02	01	H0543_215_0	7	3	Group 3	11	8a2;	16a;	2			1	0.00	0.00	2				2	
H0543	215	0	1	02	01	H0543_215_0	7	4	Group 4	01	9a1;9a2;9b;		2			1	500.00	500.00	2				2	
H0543	215	0	1	02	01	H0543_215_0	7	5	Group 5	01	15;		1	0	40	2			2				2	
H0543	215	0	1	02	01	H0543_215_0	7	6	Group 6	01	8b1;		2			1	200.00	200.00	2				2	
H0543	215	0	1	02	01	H0543_215_0	7	7	Group 7	01	8b2;		2			1	150.00	150.00	2				2	
H0543	215	0	1	02	01	H0543_215_0	7	8	Group 8	01	8b3;		2			1	20.00	20.00	2				2	
H0543	215	0	1	02	01	H0543_215_0	7	9	Group 9	10		16b;	1	0	50	2			2				2	
H0543	216	0	1	02	01	H0543_216_0	7	1	Group 1	01	7b;7d;7f;7g;8a1;17a;18a;		2			1	40.00	40.00	2				2	
H0543	216	0	1	02	01	H0543_216_0	7	2	Group 2	01	7e;7h;9c;		2			1	30.00	40.00	2				2	
H0543	216	0	1	02	01	H0543_216_0	7	3	Group 3	11	8a2;	16a;	2			1	0.00	0.00	2				2	
H0543	216	0	1	02	01	H0543_216_0	7	4	Group 4	01	9a1;9a2;9b;		2			1	500.00	500.00	2				2	
H0543	216	0	1	02	01	H0543_216_0	7	5	Group 5	01	15;		1	0	40	2			2				2	
H0543	216	0	1	02	01	H0543_216_0	7	6	Group 6	01	8b1;		2			1	200.00	200.00	2				2	
H0543	216	0	1	02	01	H0543_216_0	7	7	Group 7	01	8b2;		2			1	150.00	150.00	2				2	
H0543	216	0	1	02	01	H0543_216_0	7	8	Group 8	01	8b3;		2			1	20.00	20.00	2				2	
H0543	216	0	1	02	01	H0543_216_0	7	9	Group 9	10		16b;	1	0	50	2			2				2	
H0543	217	0	1	02	01	H0543_217_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	217	0	1	02	01	H0543_217_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	218	0	1	02	01	H0543_218_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	218	0	1	02	01	H0543_218_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	219	0	1	02	01	H0543_219_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	219	0	1	02	01	H0543_219_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	220	0	1	02	01	H0543_220_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	220	0	1	02	01	H0543_220_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	221	0	1	02	01	H0543_221_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	221	0	1	02	01	H0543_221_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	222	0	1	02	01	H0543_222_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	222	0	1	02	01	H0543_222_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	223	0	1	02	01	H0543_223_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	224	0	1	02	01	H0543_224_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	224	0	1	02	01	H0543_224_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	225	0	1	02	01	H0543_225_0	6	1	Group 1	01	7b;7d;7f;7g;17a;18a;		2			1	30.00	30.00	2				2	
H0543	225	0	1	02	01	H0543_225_0	6	2	Group 2	01	7e;7h;9c;		2			1	30.00	40.00	2				2	
H0543	225	0	1	02	01	H0543_225_0	6	3	Group 3	11	8a2;	16a;	2			1	0.00	0.00	2				2	
H0543	225	0	1	02	01	H0543_225_0	6	4	Group 4	01	8a1;8b1;8b2;8b3;9a1;9a2;9b;		1	30	30	2			2				2	
H0543	225	0	1	02	01	H0543_225_0	6	5	Group 5	01	15;		1	0	30	2			2				2	
H0543	225	0	1	02	01	H0543_225_0	6	6	Group 6	10		16b;	1	0	50	2			2				2	
H0543	226	0	1	02	01	H0543_226_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	226	0	1	02	01	H0543_226_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	227	0	1	02	01	H0543_227_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	227	0	1	02	01	H0543_227_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	228	0	1	02	01	H0543_228_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	229	0	1	02	01	H0543_229_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	229	0	1	02	01	H0543_229_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H0543	230	0	1	02	01	H0543_230_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	231	0	1	02	01	H0543_231_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	232	0	1	02	01	H0543_232_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	234	0	1	02	01	H0543_234_0	8	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	235	0	1	02	01	H0543_235_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	236	0	1	02	01	H0543_236_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	237	0	1	02	01	H0543_237_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	238	0	1	02	01	H0543_238_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	239	0	1	02	01	H0543_239_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	248	0	1	02	01	H0543_248_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0543	248	0	1	02	01	H0543_248_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	007	0	1	02	01	H0609_007_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	007	0	1	02	01	H0609_007_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	012	0	1	02	01	H0609_012_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	012	0	1	02	01	H0609_012_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	018	0	1	02	01	H0609_018_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	018	0	1	02	01	H0609_018_0	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	025	0	1	02	01	H0609_025_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	025	0	1	02	01	H0609_025_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	026	0	1	02	01	H0609_026_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	026	0	1	02	01	H0609_026_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	027	0	1	02	01	H0609_027_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	027	0	1	02	01	H0609_027_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	028	0	1	02	01	H0609_028_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	028	0	1	02	01	H0609_028_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	031	0	1	02	01	H0609_031_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	031	0	1	02	01	H0609_031_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	032	0	1	02	01	H0609_032_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	032	0	1	02	01	H0609_032_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	033	0	1	02	01	H0609_033_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	033	0	1	02	01	H0609_033_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	034	1	1	02	01	H0609_034_1	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	034	1	1	02	01	H0609_034_1	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	034	2	1	02	01	H0609_034_2	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	034	2	1	02	01	H0609_034_2	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	036	1	1	02	01	H0609_036_1	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	036	1	1	02	01	H0609_036_1	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	036	2	1	02	01	H0609_036_2	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	036	2	1	02	01	H0609_036_2	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	037	0	1	02	01	H0609_037_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	037	0	1	02	01	H0609_037_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	038	0	1	02	01	H0609_038_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	038	0	1	02	01	H0609_038_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	040	0	1	02	01	H0609_040_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	040	0	1	02	01	H0609_040_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	041	0	1	02	01	H0609_041_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	041	0	1	02	01	H0609_041_0	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	042	0	1	02	01	H0609_042_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	042	0	1	02	01	H0609_042_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	043	0	1	02	01	H0609_043_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	043	0	1	02	01	H0609_043_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	044	0	1	02	01	H0609_044_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	044	0	1	02	01	H0609_044_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	045	0	1	02	01	H0609_045_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	045	0	1	02	01	H0609_045_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	046	0	1	02	01	H0609_046_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	046	0	1	02	01	H0609_046_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	047	0	1	02	01	H0609_047_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	047	0	1	02	01	H0609_047_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	048	0	1	02	01	H0609_048_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	048	0	1	02	01	H0609_048_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	049	0	1	02	01	H0609_049_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	049	0	1	02	01	H0609_049_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	050	0	1	02	01	H0609_050_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	050	0	1	02	01	H0609_050_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	051	0	1	02	01	H0609_051_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	051	0	1	02	01	H0609_051_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	052	0	1	02	01	H0609_052_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H0609	053	0	1	02	01	H0609_053_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H0609	054	0	1	02	01	H0609_054_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	054	0	1	02	01	H0609_054_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	055	0	1	02	01	H0609_055_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	055	0	1	02	01	H0609_055_0	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	056	0	1	02	01	H0609_056_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	056	0	1	02	01	H0609_056_0	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	057	0	1	02	01	H0609_057_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H0609	058	0	1	02	01	H0609_058_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	058	0	1	02	01	H0609_058_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	059	0	1	02	01	H0609_059_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	059	0	1	02	01	H0609_059_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	060	0	1	02	01	H0609_060_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	060	0	1	02	01	H0609_060_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	061	0	1	02	01	H0609_061_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	061	0	1	02	01	H0609_061_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	062	0	1	02	01	H0609_062_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	062	0	1	02	01	H0609_062_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	063	0	1	02	01	H0609_063_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	063	0	1	02	01	H0609_063_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	064	0	1	02	01	H0609_064_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H0609	065	0	1	02	01	H0609_065_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	065	0	1	02	01	H0609_065_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	066	0	1	02	01	H0609_066_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	066	0	1	02	01	H0609_066_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	067	0	1	02	01	H0609_067_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	068	0	1	02	01	H0609_068_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	070	0	1	02	01	H0609_070_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	070	0	1	02	01	H0609_070_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0609	071	0	1	02	01	H0609_071_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0609	071	0	1	02	01	H0609_071_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0624	001	0	1	02	01	H0624_001_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H0628	001	0	1	02	01	H0628_001_0	8	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H0628	003	0	1	02	01	H0628_003_0	6	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H0628	005	0	1	02	01	H0628_005_0	8	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H0628	006	0	1	02	01	H0628_006_0	7	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H0628	007	0	1	02	01	H0628_007_0	7	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H0628	008	0	1	02	01	H0628_008_0	7	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H0628	009	0	1	02	01	H0628_009_0	6	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H0628	010	0	1	02	01	H0628_010_0	6	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H0628	017	0	1	02	01	H0628_017_0	7	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H0630	015	0	1	02	01	H0630_015_0	11	1	Primary care, prevention, hearing&vision	11	7a;9d;14a;14e1;14e2;14e3;14e4;14e5;17a;18a;	9d_2;14b;	2			1	0.00	0.00	2				2	
H0630	015	0	1	02	01	H0630_015_0	11	10	X-rays	01	8b3;		2			1	0.00	0.00	2				2	
H0630	015	0	1	02	01	H0630_015_0	11	11	Part B Clinically Administered Drugs	01	15;		1	0	20	2			2				2	
H0630	015	0	1	02	01	H0630_015_0	11	12	Outpatient Diagnostic Procedures	01	8a1;8a2;		2			1	0.00	0.00	2				2	
H0630	015	0	1	02	01	H0630_015_0	11	2	Specialist Visits	01	7d;7f;7k;		2			1	10.00	10.00	2				2	
H0630	015	0	1	02	01	H0630_015_0	11	3	Cardiac Rehab	01	3-1;3-2;		2			1	0.00	10.00	2				2	
H0630	015	0	1	02	01	H0630_015_0	11	4	Pulmonary Rehab	01	3-3;		2			1	5.00	5.00	2				2	
H0630	015	0	1	02	01	H0630_015_0	11	5	Mental Health and Substance Abuse	01	7e;7h;9c;		2			1	0.00	5.00	2				2	
H0630	015	0	1	02	01	H0630_015_0	11	6	Other Healthcare Professionals &Services	01	7g;14d;		2			1	0.00	10.00	2				2	
H0630	015	0	1	02	01	H0630_015_0	11	7	Chiropractic Services	01	7b;		2			1	20.00	20.00	2				2	
H0630	015	0	1	02	01	H0630_015_0	11	8	Outpatient Rehabilitation Services	01	7c;7i;		2			1	10.00	10.00	2				2	
H0630	015	0	1	02	01	H0630_015_0	11	9	Ultrasounds	01	8b1;		2			1	35.00	35.00	2				2	
H0630	016	0	1	02	01	H0630_016_0	11	1	Primary care, prevention, hearing&vision	11	7a;9d;14a;14e1;14e2;14e3;14e4;14e5;17a;18a;	9d_2;14b;	2			1	0.00	0.00	2				2	
H0630	016	0	1	02	01	H0630_016_0	11	10	X-rays	01	8b3;		2			1	0.00	0.00	2				2	
H0630	016	0	1	02	01	H0630_016_0	11	11	Part B Clinically Administered Drugs	01	15;		1	0	20	2			2				2	
H0630	016	0	1	02	01	H0630_016_0	11	12	Outpatient Diagnostic Procedures	01	8a1;8a2;		2			1	0.00	0.00	2				2	
H0630	016	0	1	02	01	H0630_016_0	11	2	Specialist Visits	01	7d;7f;7k;		2			1	10.00	10.00	2				2	
H0630	016	0	1	02	01	H0630_016_0	11	3	Cardiac Rehab	01	3-1;3-2;		2			1	0.00	10.00	2				2	
H0630	016	0	1	02	01	H0630_016_0	11	4	Pulmonary Rehab	01	3-3;		2			1	5.00	5.00	2				2	
H0630	016	0	1	02	01	H0630_016_0	11	5	Mental Health and Substance Abuse	01	7e;7h;9c;		2			1	0.00	0.00	2				2	
H0630	016	0	1	02	01	H0630_016_0	11	6	Other Healthcare Professionals &Services	01	7g;14d;		2			1	0.00	10.00	2				2	
H0630	016	0	1	02	01	H0630_016_0	11	7	Chiropractic Services	01	7b;		2			1	15.00	15.00	2				2	
H0630	016	0	1	02	01	H0630_016_0	11	8	Outpatient Rehabilitation Services	01	7c;7i;		2			1	10.00	10.00	2				2	
H0630	016	0	1	02	01	H0630_016_0	11	9	Ultrasounds	01	8b1;		2			1	20.00	20.00	2				2	
H0630	021	0	1	02	01	H0630_021_0	11	1	Primary care, prevention, hearing&vision	11	7a;9d;14a;14e1;14e2;14e3;14e4;14e5;17a;18a;	9d_2;14b;	2			1	0.00	0.00	2				2	
H0630	021	0	1	02	01	H0630_021_0	11	10	X-rays	01	8b3;		2			1	0.00	0.00	2				2	
H0630	021	0	1	02	01	H0630_021_0	11	11	Part B Clinically Administered Drugs	01	15;		1	0	20	2			2				2	
H0630	021	0	1	02	01	H0630_021_0	11	12	Outpatient Diagnostic Procedures	01	8a1;8a2;		2			1	0.00	0.00	2				2	
H0630	021	0	1	02	01	H0630_021_0	11	2	Specialist Visits	01	7d;7f;7k;		2			1	10.00	10.00	2				2	
H0630	021	0	1	02	01	H0630_021_0	11	3	Cardiac Rehab	01	3-1;3-2;		2			1	0.00	10.00	2				2	
H0630	021	0	1	02	01	H0630_021_0	11	4	Pulmonary Rehab	01	3-3;		2			1	5.00	5.00	2				2	
H0630	021	0	1	02	01	H0630_021_0	11	5	Mental Health and Substance Abuse	01	7e;7h;9c;		2			1	0.00	0.00	2				2	
H0630	021	0	1	02	01	H0630_021_0	11	6	Other Healthcare Professionals &Services	01	7g;14d;		2			1	0.00	10.00	2				2	
H0630	021	0	1	02	01	H0630_021_0	11	7	Chiropractic Services	01	7b;		2			1	20.00	20.00	2				2	
H0630	021	0	1	02	01	H0630_021_0	11	8	Outpatient Rehabilitation Services	01	7c;7i;		2			1	10.00	10.00	2				2	
H0630	021	0	1	02	01	H0630_021_0	11	9	Ultrasounds	01	8b1;		2			1	25.00	25.00	2				2	
H0630	023	0	1	02	01	H0630_023_0	11	1	Primary care, prevention, hearing&vision	11	7a;9d;14a;14e1;14e2;14e3;14e4;14e5;17a;18a;	9d_2;14b;	2			1	0.00	0.00	2				2	
H0630	023	0	1	02	01	H0630_023_0	11	10	X-rays	01	8b3;		2			1	5.00	5.00	2				2	
H0630	023	0	1	02	01	H0630_023_0	11	11	Part B Clinically Administered Drugs	01	15;		1	0	20	2			2				2	
H0630	023	0	1	02	01	H0630_023_0	11	12	Outpatient Diagnostic Procedures	01	8a1;8a2;		2			1	0.00	0.00	2				2	
H0630	023	0	1	02	01	H0630_023_0	11	2	Specialist Visits	01	7d;7f;7k;		2			1	20.00	20.00	2				2	
H0630	023	0	1	02	01	H0630_023_0	11	3	Cardiac Rehab	01	3-1;3-2;		2			1	0.00	20.00	2				2	
H0630	023	0	1	02	01	H0630_023_0	11	4	Pulmonary Rehab	01	3-3;		2			1	5.00	5.00	2				2	
H0630	023	0	1	02	01	H0630_023_0	11	5	Mental Health and Substance Abuse	01	7e;7h;9c;		2			1	0.00	5.00	2				2	
H0630	023	0	1	02	01	H0630_023_0	11	6	Other Healthcare Professionals &Services	01	7g;14d;		2			1	0.00	20.00	2				2	
H0630	023	0	1	02	01	H0630_023_0	11	7	Chiropractic Services	01	7b;		2			1	20.00	20.00	2				2	
H0630	023	0	1	02	01	H0630_023_0	11	8	Outpatient Rehabilitation Services	01	7c;7i;		2			1	20.00	20.00	2				2	
H0630	023	0	1	02	01	H0630_023_0	11	9	Ultrasounds	01	8b1;		2			1	25.00	25.00	2				2	
H0630	025	0	1	02	01	H0630_025_0	11	1	Primary care, prevention, hearing&vision	11	7a;9d;14a;14e1;14e2;14e3;14e4;14e5;17a;18a;	9d_2;14b;	2			1	0.00	0.00	2				2	
H0630	025	0	1	02	01	H0630_025_0	11	10	X-rays	01	8b3;		2			1	0.00	0.00	2				2	
H0630	025	0	1	02	01	H0630_025_0	11	11	Part B Clinically Administered Drugs	01	15;		1	0	20	2			2				2	
H0630	025	0	1	02	01	H0630_025_0	11	12	Outpatient Diagnostic Procedures	01	8a1;8a2;		2			1	0.00	0.00	2				2	
H0630	025	0	1	02	01	H0630_025_0	11	2	Specialist Visits	01	7d;7f;7k;		2			1	35.00	35.00	2				2	
H0630	025	0	1	02	01	H0630_025_0	11	3	Cardiac Rehab	01	3-1;3-2;		2			1	0.00	35.00	2				2	
H0630	025	0	1	02	01	H0630_025_0	11	4	Pulmonary Rehab	01	3-3;		2			1	5.00	5.00	2				2	
H0630	025	0	1	02	01	H0630_025_0	11	5	Mental Health and Substance Abuse	01	7e;7h;9c;		2			1	5.00	10.00	2				2	
H0630	025	0	1	02	01	H0630_025_0	11	6	Other Healthcare Professionals &Services	01	7g;14d;		2			1	0.00	35.00	2				2	
H0630	025	0	1	02	01	H0630_025_0	11	7	Chiropractic Services	01	7b;		2			1	20.00	20.00	2				2	
H0630	025	0	1	02	01	H0630_025_0	11	8	Outpatient Rehabilitation Services	01	7c;7i;		2			1	25.00	25.00	2				2	
H0630	025	0	1	02	01	H0630_025_0	11	9	Ultrasounds	01	8b1;		2			1	40.00	40.00	2				2	
H0630	026	0	1	02	01	H0630_026_0	10	1	Primary care, prevention, hearing&vision	11	7a;9d;14a;14e1;14e2;14e3;14e4;14e5;17a;18a;	9d_2;14b;	2			1	0.00	0.00	2				2	
H0630	026	0	1	02	01	H0630_026_0	10	10	X-rays	01	8b3;		2			1	0.00	0.00	2				2	
H0630	026	0	1	02	01	H0630_026_0	10	11	Part B Clinically Administered Drugs	01	15;		1	0	20	2			2				2	
H0630	026	0	1	02	01	H0630_026_0	10	12	Outpatient Diagnostic Procedures	01	8a1;8a2;		2			1	0.00	0.00	2				2	
H0630	026	0	1	02	01	H0630_026_0	10	2	Specialist Visits	01	7d;7f;7k;		2			1	35.00	35.00	2				2	
H0630	026	0	1	02	01	H0630_026_0	10	3	Cardiac Rehab	01	3-1;3-2;		2			1	0.00	35.00	2				2	
H0630	026	0	1	02	01	H0630_026_0	10	4	Pulmonary Rehab	01	3-3;		2			1	5.00	5.00	2				2	
H0630	026	0	1	02	01	H0630_026_0	10	5	Mental Health and Substance Abuse	01	7e;7h;9c;		2			1	5.00	10.00	2				2	
H0630	026	0	1	02	01	H0630_026_0	10	6	Other Healthcare Professionals &Services	01	7g;14d;		2			1	0.00	35.00	2				2	
H0630	026	0	1	02	01	H0630_026_0	10	7	Chiropractic Services	01	7b;		2			1	20.00	20.00	2				2	
H0630	026	0	1	02	01	H0630_026_0	10	8	Outpatient Rehabilitation Services	01	7c;7i;		2			1	25.00	25.00	2				2	
H0630	026	0	1	02	01	H0630_026_0	10	9	Ultrasounds	01	8b1;		2			1	40.00	40.00	2				2	
H0755	030	0	1	02	01	H0755_030_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0755	031	0	1	02	01	H0755_031_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0755	031	0	1	02	01	H0755_031_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H0755	032	0	1	02	01	H0755_032_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0755	033	0	1	02	01	H0755_033_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0755	037	0	1	02	01	H0755_037_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0755	037	0	1	02	01	H0755_037_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0755	038	0	1	02	01	H0755_038_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0755	044	0	1	02	01	H0755_044_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0755	045	0	1	02	01	H0755_045_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H0755	045	0	1	02	01	H0755_045_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H0907	001	0	1	02	01	H0907_001_0	7	1	DENTAL SUPPLEMENTAL (PREV & COMP)	10		16a;16b;	2			1	0.00	0.00	1	6000.00	3		2	
H0907	002	0	1	02	01	H0907_002_0	7	1	DENTAL SUPPLEMENTAL (PREV & COMP)	10		16a;16b;	2			1	0.00	0.00	1	2000.00	3		2	
H0913	002	0	1	02	01	H0913_002_0	19	1	50%	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;	1	50	50	2			2				2	
H0913	002	0	1	02	01	H0913_002_0	19	2	Insulin/Part B Drugs	01	15;		1	0	20	1	35.00	35.00	2				2	
H0913	002	0	1	02	01	H0913_002_0	19	3	Dialysis	01	12;		1	20	20	2			2				2	
H1016	025	0	1	02	01	H1016_025_0	9	1	PCP and Specialist Services	01	7a;7d;		2			1	0.00	10.00	2				2	
H1016	026	0	1	02	01	H1016_026_0	9	1	Point of Service Group 1	01	7a;7d;		2			1	0.00	10.00	2				2	
H1019	057	0	1	02	01	H1019_057_0	6	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;5;6;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a2;9a2;9c;9d;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;13a;	2			1	0.00	0.00	2				2	
H1019	057	0	1	02	01	H1019_057_0	6	2	Point of Service Group 2	01	9b;		2			1	0.00	20.00	2				2	
H1019	057	0	1	02	01	H1019_057_0	6	3	Point of Service Group 3	01	8a1;8b1;8b3;9a1;		2			1	0.00	25.00	2				2	
H1019	057	0	1	02	01	H1019_057_0	6	4	Point of Service Group 4	01	10a1;		2			1	200.00	200.00	2				2	
H1019	057	0	1	02	01	H1019_057_0	6	5	Point of Service Group 6	01	10a2;12;		1	20	20	2			2				2	
H1019	057	0	1	02	01	H1019_057_0	6	6	Point of Service Group 7	01	8b2;		1	20	20	1	0.00	0.00	2				2	
H1019	057	0	1	02	01	H1019_057_0	6	7	Point of Service Group 5	01	15;		1	19	19	2			2				2	
H1019	057	0	1	02	01	H1019_057_0	6	8	Point of Service Group 8	01	11a;		1	10	20	2			2				2	
H1019	110	0	1	02	01	H1019_110_0	7	1	Point of Service Group 1	11	6;8a2;9a2;9d;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;	2			1	0.00	0.00	2				2	
H1019	110	0	1	02	01	H1019_110_0	7	10	Point of Service Group 10	01	11a;		1	10	20	2			2				2	
H1019	110	0	1	02	01	H1019_110_0	7	11	Point of Service Group 11	01	8b2;		1	20	20	1	20.00	55.00	2				2	
H1019	110	0	1	02	01	H1019_110_0	7	2	Point of Service Group 2	01	11c;		2			1	0.00	10.00	2				2	
H1019	110	0	1	02	01	H1019_110_0	7	3	Point of Service Group 3	01	8a1;8b1;9a1;		2			1	0.00	100.00	2				2	
H1019	110	0	1	02	01	H1019_110_0	7	4	Point of Service Group 4	01	17a;		2			1	0.00	20.00	2				2	
H1019	110	0	1	02	01	H1019_110_0	7	5	Point of Service Group 5	01	9b;		2			1	0.00	95.00	2				2	
H1019	110	0	1	02	01	H1019_110_0	7	6	Point of Service Group 6	01	10a1;		2			1	150.00	150.00	2				2	
H1019	110	0	1	02	01	H1019_110_0	7	7	Point of Service Group 7	01	8b3;		2			1	20.00	100.00	2				2	
H1019	110	0	1	02	01	H1019_110_0	7	8	Point of Service Group 8	11	3-1;3-2;3-3;3-4;5;7b;7c;7d;7e;7f;7g;7h;7i;7k;9c;16b;18a;	13a;	2			1	20.00	20.00	2				2	
H1019	110	0	1	02	01	H1019_110_0	7	9	Point of Service Group 9	01	10a2;11b;12;15;		1	20	20	2			2				2	
H1019	141	0	1	02	01	H1019_141_0	11	1	Point of Service Group 1	11	6;8a2;9a2;9d;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;	2			1	0.00	0.00	2				2	
H1019	141	0	1	02	01	H1019_141_0	11	10	Point of Service Group 10	01	11a;		1	10	20	2			2				2	
H1019	141	0	1	02	01	H1019_141_0	11	11	Point of Service Group 11	01	8b2;		1	20	20	1	20.00	40.00	2				2	
H1019	141	0	1	02	01	H1019_141_0	11	2	Point of Service Group 2	01	11c;		2			1	0.00	10.00	2				2	
H1019	141	0	1	02	01	H1019_141_0	11	3	Point of Service Group 3	01	17a;		2			1	0.00	20.00	2				2	
H1019	141	0	1	02	01	H1019_141_0	11	4	Point of Service Group 4	01	9b;		2			1	0.00	40.00	2				2	
H1019	141	0	1	02	01	H1019_141_0	11	5	Point of Service Group 5	01	8a1;8b1;9a1;		2			1	0.00	55.00	2				2	
H1019	141	0	1	02	01	H1019_141_0	11	6	Point of Service Group 6	01	10a1;		2			1	120.00	120.00	2				2	
H1019	141	0	1	02	01	H1019_141_0	11	7	Point of Service Group 7	11	3-1;3-2;3-3;3-4;5;7b;7c;7d;7e;7f;7g;7h;7i;7k;9c;16b;18a;	13a;	2			1	20.00	20.00	2				2	
H1019	141	0	1	02	01	H1019_141_0	11	8	Point of Service Group 8	01	8b3;		2			1	20.00	40.00	2				2	
H1019	141	0	1	02	01	H1019_141_0	11	9	Point of Service Group 9	01	10a2;11b;12;15;		1	20	20	2			2				2	
H1019	142	0	1	02	01	H1019_142_0	5	1	Point of Service Group 1	11	6;8a2;9a2;9d;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;	2			1	0.00	0.00	2				2	
H1019	142	0	1	02	01	H1019_142_0	5	10	Point of Service Group 10	01	11a;		1	10	20	2			2				2	
H1019	142	0	1	02	01	H1019_142_0	5	11	Point of Service Group 11	01	8b2;		1	20	20	1	20.00	40.00	2				2	
H1019	142	0	1	02	01	H1019_142_0	5	2	Point of Service Group 2	01	11c;		2			1	0.00	10.00	2				2	
H1019	142	0	1	02	01	H1019_142_0	5	3	Point of Service Group 3	01	17a;		2			1	0.00	20.00	2				2	
H1019	142	0	1	02	01	H1019_142_0	5	4	Point of Service Group 4	01	9b;		2			1	0.00	40.00	2				2	
H1019	142	0	1	02	01	H1019_142_0	5	5	Point of Service Group 5	01	8a1;8b1;9a1;		2			1	0.00	55.00	2				2	
H1019	142	0	1	02	01	H1019_142_0	5	6	Point of Service Group 6	01	10a1;		2			1	120.00	120.00	2				2	
H1019	142	0	1	02	01	H1019_142_0	5	7	Point of Service Group 7	11	3-1;3-2;3-3;3-4;5;7b;7c;7d;7e;7f;7g;7h;7i;7k;9c;16b;18a;	13a;	2			1	20.00	20.00	2				2	
H1019	142	0	1	02	01	H1019_142_0	5	8	Point of Service Group 8	01	8b3;		2			1	20.00	40.00	2				2	
H1019	142	0	1	02	01	H1019_142_0	5	9	Point of Service Group 9	01	10a2;11b;12;15;		1	20	20	2			2				2	
H1019	143	0	1	02	01	H1019_143_0	3	1	Point of Service Group 1	11	6;8a2;9a2;9d;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;	2			1	0.00	0.00	2				2	
H1019	143	0	1	02	01	H1019_143_0	3	10	Point of Service Group 10	01	11a;		1	20	20	1	0.00	0.00	2				2	
H1019	143	0	1	02	01	H1019_143_0	3	11	Point of Service Group 11	01	8b2;		1	20	20	1	40.00	50.00	2				2	
H1019	143	0	1	02	01	H1019_143_0	3	2	Point of Service Group 2	01	11c;		2			1	0.00	10.00	2				2	
H1019	143	0	1	02	01	H1019_143_0	3	3	Point of Service Group 3	01	9b;		2			1	0.00	200.00	2				2	
H1019	143	0	1	02	01	H1019_143_0	3	4	Point of Service Group 4	01	8a1;8b1;9a1;		2			1	0.00	250.00	2				2	
H1019	143	0	1	02	01	H1019_143_0	3	5	Point of Service Group 5	01	17a;		2			1	0.00	50.00	2				2	
H1019	143	0	1	02	01	H1019_143_0	3	6	Point of Service Group 6	01	10a1;		2			1	240.00	240.00	2				2	
H1019	143	0	1	02	01	H1019_143_0	3	7	Point of Service Group 7	01	8b3;		2			1	50.00	175.00	2				2	
H1019	143	0	1	02	01	H1019_143_0	3	8	Point of Service Group 8	11	3-1;3-2;3-3;3-4;5;7b;7c;7d;7e;7f;7g;7h;7i;7k;9c;16b;18a;	13a;	2			1	50.00	50.00	2				2	
H1019	143	0	1	02	01	H1019_143_0	3	9	Point of Service Group 9	01	10a2;11b;12;15;		1	20	20	2			2				2	
H1035	002	0	1	02	01	H1035_002_0	10	1	Group 1 - 20% coinsurance	01	6;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;11a;11b;11c;14a;15;		1	20	20	2			2				2	
H1035	002	0	1	02	01	H1035_002_0	10	2	Group 2 - $40 copayment	01	3-1;3-2;3-3;3-4;7a;7b;7c;7d;7e;7f;7h;7i;7k;9c;16b;		2			1	40.00	40.00	2				2	
H1036	137	0	1	02	01	H1036_137_0	7	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	1500.00	3		2	
H1036	233	0	1	02	01	H1036_233_0	6	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	1500.00	3		2	
H1036	291	0	1	02	01	H1036_291_0	6	1	Point of Service Group 2	10		16a;16b;	2			1	0.00	0.00	1	2000.00	3		2	
H1045	025	0	1	02	01	H1045_025_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1045	025	0	1	02	01	H1045_025_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H1045	026	0	1	02	01	H1045_026_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1045	026	0	1	02	01	H1045_026_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H1045	028	0	1	02	01	H1045_028_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1045	028	0	1	02	01	H1045_028_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H1045	030	0	1	02	01	H1045_030_0	9	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1045	030	0	1	02	01	H1045_030_0	9	2	Group 2	10		16b;	1	0	50	2			2				2	
H1045	031	0	1	02	01	H1045_031_0	9	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1045	031	0	1	02	01	H1045_031_0	9	2	Group 2	10		16b;	1	0	50	2			2				2	
H1045	033	0	1	02	01	H1045_033_0	8	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1045	033	0	1	02	01	H1045_033_0	8	2	Group 2	10		16b;	1	0	50	2			2				2	
H1045	034	0	1	02	01	H1045_034_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1045	034	0	1	02	01	H1045_034_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H1045	036	0	1	02	01	H1045_036_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1045	036	0	1	02	01	H1045_036_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H1045	039	0	1	02	01	H1045_039_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H1045	041	0	1	02	01	H1045_041_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1045	041	0	1	02	01	H1045_041_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H1045	042	0	1	02	01	H1045_042_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1045	042	0	1	02	01	H1045_042_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H1045	043	0	1	02	01	H1045_043_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1045	043	0	1	02	01	H1045_043_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H1045	045	0	1	02	01	H1045_045_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1045	045	0	1	02	01	H1045_045_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H1045	048	1	1	02	01	H1045_048_1	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1045	048	1	1	02	01	H1045_048_1	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H1045	048	2	1	02	01	H1045_048_2	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1045	048	2	1	02	01	H1045_048_2	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H1045	048	3	1	02	01	H1045_048_3	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1045	048	3	1	02	01	H1045_048_3	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H1045	048	4	1	02	01	H1045_048_4	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1045	048	4	1	02	01	H1045_048_4	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H1045	055	0	1	02	01	H1045_055_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1045	055	0	1	02	01	H1045_055_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H1045	056	0	1	02	01	H1045_056_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1045	056	0	1	02	01	H1045_056_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H1099	001	0	1	02	01	H1099_001_0	4	1	Coinsurance Group	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H1112	034	0	1	02	01	H1112_034_0	5	1	20%	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	20	20	2			2				2	
H1112	034	0	1	02	01	H1112_034_0	5	2	Insulin & Part B Drugs	01	15;		1	0	20	1	35.00	35.00	2				2	
H1170	013	0	1	02	01	H1170_013_0	9	1	Part B Drugs	01	15;		1	20	20	2			2				2	
H1170	013	0	1	02	01	H1170_013_0	9	2	Primary Care Office Visits	01	7a;		2			1	25.00	25.00	2				2	
H1170	013	0	1	02	01	H1170_013_0	9	3	Outpatient Tests and Services	01	8a1;8a2;8b1;8b3;14e3;		2			1	50.00	50.00	2				2	
H1170	013	0	1	02	01	H1170_013_0	9	4	Specialty Care Office Visits	01	7d;7f;7g;17a;18a;		2			1	0.00	50.00	2				2	
H1170	013	0	1	02	01	H1170_013_0	9	5	Therapy Visits	01	3-1;3-2;3-3;3-4;7c;7i;		2			1	50.00	50.00	2				2	
H1170	013	0	1	02	01	H1170_013_0	9	6	Blood	11	9d;	9d_2;	2			1	50.00	50.00	2				2	
H1170	013	0	1	02	01	H1170_013_0	9	7	Preventive Services	11	14a;14e1;	14b;	2			1	0.00	0.00	2				2	
H1170	013	0	1	02	01	H1170_013_0	9	8	Mental Health Care	01	7e;7h;7k;9c;		2			1	25.00	50.00	2				2	
H1206	001	0	1	02	01	H1206_001_0	5	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H1206	002	0	1	02	01	H1206_002_0	5	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H1277	001	0	1	02	01	H1277_001_0	10	1	$0 Copay Group	01	7a;8a2;8b3;		2			2			2				2	
H1277	001	0	1	02	01	H1277_001_0	10	2	$10 Copay Group	01	7d;		2			1	10.00	10.00	2				2	
H1277	001	0	1	02	01	H1277_001_0	10	3	$100 Copay Group	01	9a2;		2			1	100.00	100.00	2				2	
H1277	001	0	1	02	01	H1277_001_0	10	4	20% Coinsurance Group	01	8a1;8b1;8b2;9a1;9b;		1	20	20	2			2				2	
H1277	002	0	1	02	01	H1277_002_0	10	1	$0 Copay Group	01	7a;8a2;8b3;		2			2			2				2	
H1277	002	0	1	02	01	H1277_002_0	10	2	$10 Copay Group	01	7d;		2			1	10.00	10.00	2				2	
H1277	002	0	1	02	01	H1277_002_0	10	3	$100 Copay Group	01	9a2;		2			1	100.00	100.00	2				2	
H1277	002	0	1	02	01	H1277_002_0	10	4	20% Coinsurance Group	01	8a1;8b1;8b2;9a1;9b;		1	20	20	2			2				2	
H1277	004	0	1	02	01	H1277_004_0	10	1	$0 Copay Group	01	7a;8a2;		2			2			2				2	
H1277	004	0	1	02	01	H1277_004_0	10	2	$100 Copay Group	01	9a2;		2			1	100.00	100.00	2				2	
H1277	004	0	1	02	01	H1277_004_0	10	3	20% Coinsurance Group	01	7d;8a1;8b1;8b2;8b3;9a1;9b;		1	20	20	2			2				2	
H1350	806	0	1	02	01	H1350_806_0	3	1	Point of Service Group 1	01	6;14a;		2			2			2				2	
H1350	807	0	1	02	01	H1350_807_0	3	1	Point of Service Group 1	01	6;14a;		2			2			2				2	
H1352	805	0	1	02	01	H1352_805_0	3	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H1352	805	0	1	02	01	H1352_805_0	3	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H1360	001	0	1	02	01	H1360_001_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H1416	009	0	1	02	01	H1416_009_0	9	1	40%	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	40	40	2			2				2	
H1416	009	0	1	02	01	H1416_009_0	9	2	Insulin/Part B Drugs and Dialysis	01	12;15;		1	0	20	1	35.00	35.00	2				2	
H1416	026	0	1	02	01	H1416_026_0	19	1	40%	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	40	40	2			2				2	
H1416	026	0	1	02	01	H1416_026_0	19	2	Insulin/Part B Drugs and Dialysis	01	12;15;		1	0	20	1	35.00	35.00	2				2	
H1416	033	0	1	02	01	H1416_033_0	19	1	40%	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	40	40	2			2				2	
H1416	033	0	1	02	01	H1416_033_0	19	2	Insulin/Part B Drugs and Dialysis	01	12;15;		1	0	20	1	35.00	35.00	2				2	
H1416	043	0	1	02	01	H1416_043_0	19	1	40%	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	40	40	2			2				2	
H1416	043	0	1	02	01	H1416_043_0	19	2	Insulin/Part B Drugs and Dialysis	01	12;15;		1	0	20	1	35.00	35.00	2				2	
H1416	058	0	1	02	01	H1416_058_0	16	1	20%	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	20	20	2			2				2	
H1416	058	0	1	02	01	H1416_058_0	16	2	Insulin & Part B Drugs	01	15;		1	0	20	1	35.00	35.00	2				2	
H1416	059	0	1	02	01	H1416_059_0	16	1	20%	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	20	20	2			2				2	
H1416	059	0	1	02	01	H1416_059_0	16	2	Insulin & Part B Drugs	01	15;		1	0	20	1	35.00	35.00	2				2	
H1416	060	0	1	02	01	H1416_060_0	16	1	20%	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	20	20	2			2				2	
H1416	060	0	1	02	01	H1416_060_0	16	2	Insulin & Part B Drugs	01	15;		1	0	20	1	35.00	35.00	2				2	
H1416	061	0	1	02	01	H1416_061_0	16	1	20%	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	20	20	2			2				2	
H1416	061	0	1	02	01	H1416_061_0	16	2	Insulin & Part B Drugs	01	15;		1	0	20	1	35.00	35.00	2				2	
H1416	077	0	1	02	01	H1416_077_0	20	1	40%	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	40	40	2			2				2	
H1416	077	0	1	02	01	H1416_077_0	20	2	Insulin/Part B Drugs	01	15;		1	0	20	1	35.00	35.00	2				2	
H1416	077	0	1	02	01	H1416_077_0	20	3	Dialysis	01	12;		1	20	20	2			2				2	
H1416	082	0	1	02	01	H1416_082_0	9	1	40%	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	40	40	2			2				2	
H1416	082	0	1	02	01	H1416_082_0	9	2	Insulin/Part B Drugs and Dialysis	01	12;15;		1	0	20	1	35.00	35.00	2				2	
H1463	015	0	1	02	01	H1463_015_0	5	1	POS Group 1=$0	11	9d;14a;	14c7;	2			1	0.00	0.00	2				2	
H1463	015	0	1	02	01	H1463_015_0	5	10	POS Group 10=50%	01	12;		1	50	50	2			2				2	
H1463	015	0	1	02	01	H1463_015_0	5	11	POS Group 11=$15	10		13a;	2			1	15.00	15.00	2				2	
H1463	015	0	1	02	01	H1463_015_0	5	12	POS Group 12=$200.00	10		17b;	2			2			1	200.00	3		2	
H1463	015	0	1	02	01	H1463_015_0	5	13	POS Group 13= $425	01	10a2;		2			1	425.00	425.00	2				2	
H1463	015	0	1	02	01	H1463_015_0	5	14	POS Group 14=$350	01	10a1;		2			1	350.00	350.00	2				2	
H1463	015	0	1	02	01	H1463_015_0	5	2	POS Group 2=$20	01	16b;		2			1	20.00	20.00	2				2	
H1463	015	0	1	02	01	H1463_015_0	5	3	POS Group 3=$40	01	17b;18a;		2			1	40.00	40.00	2				2	
H1463	015	0	1	02	01	H1463_015_0	5	4	POS Group 4=$50	11	3-1;3-2;3-3;3-4;6;7a;7b;7c;7e;7f;7h;7i;8a1;8a2;8b1;8b2;8b3;9c;14d;14e1;14e2;14e3;14e4;14e5;17a;	14b;	2			1	50.00	50.00	2				2	
H1463	015	0	1	02	01	H1463_015_0	5	5	POS Group 5=$65	01	5;7d;7g;7k;		2			1	65.00	65.00	2				2	
H1463	015	0	1	02	01	H1463_015_0	5	6	POS Group 6=$2000	10		16a;16b;	1	0	40	2			1	2000.00	3		2	
H1463	015	0	1	02	01	H1463_015_0	5	7	POS Group 7=$360	10		14c4;	2			2			1	360.00	3		2	
H1463	015	0	1	02	01	H1463_015_0	5	8	POS Group 8=20%	01	11a;11b;11c;		1	20	20	2			2				2	
H1463	015	0	1	02	01	H1463_015_0	5	9	POS Group 9=25%	01	9a1;9a2;9b;15;		1	25	25	2			2				2	
H1463	019	0	1	02	01	H1463_019_0	5	1	POS Group 1=$0	11	9d;	14c7;	2			1	0.00	0.00	2				2	
H1463	019	0	1	02	01	H1463_019_0	5	10	POS Group 11=20%	01	11a;11b;11c;		1	20	20	2			2				2	
H1463	019	0	1	02	01	H1463_019_0	5	11	POS Group 12=25%	01	15;		1	25	25	2			2				2	
H1463	019	0	1	02	01	H1463_019_0	5	12	POS Group 13=$200.00	10		17b;	2			2			1	200.00	3		2	
H1463	019	0	1	02	01	H1463_019_0	5	13	POS Group 14=$400	01	10a2;		2			1	400.00	400.00	2				2	
H1463	019	0	1	02	01	H1463_019_0	5	14	POS Group 15=$275	01	10a1;		2			1	275.00	275.00	2				2	
H1463	019	0	1	02	01	H1463_019_0	5	2	POS Group 2=$20	11	16b;	13a;	2			1	20.00	20.00	2				2	
H1463	019	0	1	02	01	H1463_019_0	5	3	POS Group #3=$30	11	3-1;3-2;3-3;3-4;6;7c;7i;8a1;8a2;8b1;8b2;8b3;14a;14d;14e1;14e2;14e3;14e4;14e5;	14b;	2			1	30.00	30.00	2				2	
H1463	019	0	1	02	01	H1463_019_0	5	4	POS Group 4=$40	01	7a;7d;7e;7f;7g;7h;7k;9c;17a;17b;18a;		2			1	40.00	40.00	2				2	
H1463	019	0	1	02	01	H1463_019_0	5	5	POS Group 5= $45	01	5;7b;9a2;		2			1	45.00	45.00	2				2	
H1463	019	0	1	02	01	H1463_019_0	5	6	POS Group 6=$2000	10		16a;16b;	1	0	40	2			1	2000.00	3		2	
H1463	019	0	1	02	01	H1463_019_0	5	7	POS Group 7=50%	01	12;		1	50	50	2			2				2	
H1463	019	0	1	02	01	H1463_019_0	5	8	POS Group 8=$350	01	9a1;9b;		2			1	350.00	350.00	2				2	
H1463	019	0	1	02	01	H1463_019_0	5	9	POS Group 10=Fitness Benefit	10		14c4;	2			2			1	360.00	3		2	
H1463	042	0	1	02	01	H1463_042_0	5	1	POS Group 1=$0	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		2			2			2				2	
H1463	042	0	1	02	01	H1463_042_0	5	2	POS Group 2=$360	10		14c4;	2			2			1	360.00	3		2	
H1463	042	0	1	02	01	H1463_042_0	5	3	POS Group 3=$2,000	10		16a;16b;	1	0	40	2			1	2000.00	3		2	
H1463	044	0	1	02	01	H1463_044_0	5	1	POS Group=$0	11	3-1;3-2;3-3;3-4;6;7a;8a1;8a2;8b3;9d;14a;14d;14e1;14e2;14e3;14e4;14e5;17a;17b;	14b;14c7;	2			1	0.00	0.00	2				2	
H1463	044	0	1	02	01	H1463_044_0	5	10	POS Group-$45	01	7k;		2			1	45.00	45.00	2				2	
H1463	044	0	1	02	01	H1463_044_0	5	11	POS Group=$0 - 20%	01	11a;11c;		1	20	20	1	0.00	0.00	2				2	
H1463	044	0	1	02	01	H1463_044_0	5	12	POS Group=$250	01	9a1;9b;		2			1	250.00	250.00	2				2	
H1463	044	0	1	02	01	H1463_044_0	5	13	POS Group=$300	01	10a1;10a2;		2			1	300.00	300.00	2				2	
H1463	044	0	1	02	01	H1463_044_0	5	14	POS Group = 30%	01	18a;		1	30	30	2			2				2	
H1463	044	0	1	02	01	H1463_044_0	5	15	POS Group=$25	01	7i;		2			1	25.00	25.00	2				2	
H1463	044	0	1	02	01	H1463_044_0	5	2	POS Group=$2000	10		16a;16b;	1	0	40	2			1	2000.00	3		2	
H1463	044	0	1	02	01	H1463_044_0	5	3	POS Group=$360	10		14c4;	2			2			1	360.00	3		2	
H1463	044	0	1	02	01	H1463_044_0	5	4	POS Group 11=$10	10		13a;	2			1	10.00	10.00	2				2	
H1463	044	0	1	02	01	H1463_044_0	5	5	POS Group=$200.00	10		17b;	2			2			1	200.00	3		2	
H1463	044	0	1	02	01	H1463_044_0	5	6	POS Group =20%	01	5;8b1;8b2;9a2;9c;11b;12;15;		1	20	20	2			2				2	
H1463	044	0	1	02	01	H1463_044_0	5	7	POS Group=$20	01	7b;		2			1	20.00	20.00	2				2	
H1463	044	0	1	02	01	H1463_044_0	5	8	POS Group=$40	01	7c;7d;7e;7f;7h;16b;		2			1	40.00	40.00	2				2	
H1463	044	0	1	02	01	H1463_044_0	5	9	POS Group: $10-$40	01	7g;		2			1	10.00	40.00	2				2	
H1463	811	0	1	02	01	H1463_811_0	3	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H1463	811	0	1	02	01	H1463_811_0	3	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H1463	812	0	1	02	01	H1463_812_0	3	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H1463	812	0	1	02	01	H1463_812_0	3	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H1463	813	0	1	02	01	H1463_813_0	3	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H1463	813	0	1	02	01	H1463_813_0	3	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H1463	814	0	1	02	01	H1463_814_0	3	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H1463	814	0	1	02	01	H1463_814_0	3	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H1526	001	0	1	02	01	H1526_001_0	12	1	$0 Costshare	11	3-1;3-2;6;7a;7f;8a2;8b3;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;	7f_2;13c;14b;14c1;14c4;14c6;14c8;14c10;14c11;14c13;14c14;14c20;14c21;	2			2			2				2	
H1526	001	0	1	02	01	H1526_001_0	12	10	$0-175 Copay	01	9a1;		2			1	0.00	175.00	2				2	
H1526	001	0	1	02	01	H1526_001_0	12	11	$175 Copay	01	9a2;		2			1	175.00	175.00	2				2	
H1526	001	0	1	02	01	H1526_001_0	12	12	$15-25 Copay	01	9c;		2			1	15.00	25.00	2				2	
H1526	001	0	1	02	01	H1526_001_0	12	13	$200 Copay	01	10a1;		2			1	200.00	200.00	2				2	
H1526	001	0	1	02	01	H1526_001_0	12	14	$25 per month	10		13b;	2			2			1	25.00	7		2	
H1526	001	0	1	02	01	H1526_001_0	12	15	0-20% Coinsurance; $35 Copay	01	15;		1	0	20	1	35.00	35.00	2				2	
H1526	001	0	1	02	01	H1526_001_0	12	16	$ 2500 Flex Card	11	16b;17a;17b;18a;	16a;16b;17a;17b;18a;18a2;18b;	2			2			2				2	
H1526	001	0	1	02	01	H1526_001_0	12	17	$70 Copay	01	5;		2			1	70.00	70.00	2				2	
H1526	001	0	1	02	01	H1526_001_0	12	2	$10 Copay	01	3-3;3-4;7c;7i;		2			1	10.00	10.00	2				2	
H1526	001	0	1	02	01	H1526_001_0	12	3	$75 Copay	01	9b;		2			1	75.00	75.00	2				2	
H1526	001	0	1	02	01	H1526_001_0	12	4	$20 Copay	11	7b;7g;	7b;13a;	2			1	20.00	20.00	2				2	
H1526	001	0	1	02	01	H1526_001_0	12	5	$0-10 Copay	01	7d;		2			1	0.00	10.00	2				2	
H1526	001	0	1	02	01	H1526_001_0	12	6	$10-25 Copay	01	7e;7h;		2			1	10.00	25.00	2				2	
H1526	001	0	1	02	01	H1526_001_0	12	7	$25 Copay	01	7k;		2			1	25.00	25.00	2				2	
H1526	001	0	1	02	01	H1526_001_0	12	8	$50 Copay	01	8a1;8b1;		2			1	50.00	50.00	2				2	
H1526	001	0	1	02	01	H1526_001_0	12	9	20% Coinsurance	11	8b2;9d;10a2;11a;11b;12;	9d_2;	1	20	20	2			2				2	
H1526	002	0	1	02	01	H1526_002_0	10	1	$0 Costshare	11	6;8a2;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;	13c;14b;14c1;14c4;14c6;14c8;14c10;14c11;14c13;14c14;14c20;14c21;	2			2			2				2	
H1526	002	0	1	02	01	H1526_002_0	10	2	20% Coinsurance	11	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;12;	7b;7f_2;9d_2;13a;	1	20	20	2			2				2	
H1526	002	0	1	02	01	H1526_002_0	10	3	0-20% Coinsurance; $35 Copay	01	15;		1	0	20	1	35.00	35.00	2				2	
H1526	002	0	1	02	01	H1526_002_0	10	4	$135 Per Month	10		13b;	2			2			1	135.00	7		2	
H1526	002	0	1	02	01	H1526_002_0	10	5	$3500 Flex Card	11	16b;17a;17b;18a;	16a;16b;17a;17b;18a;18a2;18b;	2			2			2				2	
H1526	003	0	1	02	01	H1526_003_0	11	1	$0 Costshare	11	3-1;3-2;6;7a;7f;8a2;8b3;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;	13c;14b;14c1;14c4;14c6;14c8;14c10;14c11;14c13;14c14;14c20;14c21;	2			2			2				2	
H1526	003	0	1	02	01	H1526_003_0	11	10	$0-175 Copay	01	9a1;		2			1	0.00	175.00	2				2	
H1526	003	0	1	02	01	H1526_003_0	11	11	$175 Copay	01	9a2;		2			1	175.00	175.00	2				2	
H1526	003	0	1	02	01	H1526_003_0	11	12	$15-25 Copay	01	9c;		2			1	15.00	25.00	2				2	
H1526	003	0	1	02	01	H1526_003_0	11	13	$200 Copay	01	10a1;		2			1	200.00	200.00	2				2	
H1526	003	0	1	02	01	H1526_003_0	11	14	$25 per month	10		13b;	2			2			1	25.00	7		2	
H1526	003	0	1	02	01	H1526_003_0	11	15	0-20% Coinsurance; $35 Copay	01	15;		1	0	20	1	35.00	35.00	2				2	
H1526	003	0	1	02	01	H1526_003_0	11	16	$ 2500 Flex Card	11	16b;17a;17b;18a;	16a;16b;17a;17b;18a;18a2;18b;	2			2			2				2	
H1526	003	0	1	02	01	H1526_003_0	11	17	$70 Copay	01	5;		2			1	70.00	70.00	2				2	
H1526	003	0	1	02	01	H1526_003_0	11	2	$10 Copay	01	3-3;3-4;7c;7i;		2			1	10.00	10.00	2				2	
H1526	003	0	1	02	01	H1526_003_0	11	3	$75 Copay	01	9b;		2			1	75.00	75.00	2				2	
H1526	003	0	1	02	01	H1526_003_0	11	4	$20 Copay	11	7b;7g;	7b;13a;	2			1	20.00	20.00	2				2	
H1526	003	0	1	02	01	H1526_003_0	11	5	$0-10 Copay	01	7d;		2			1	0.00	10.00	2				2	
H1526	003	0	1	02	01	H1526_003_0	11	6	$10-25 Copay	01	7e;7h;		2			1	10.00	25.00	2				2	
H1526	003	0	1	02	01	H1526_003_0	11	7	$25 Copay	01	7k;		2			1	25.00	25.00	2				2	
H1526	003	0	1	02	01	H1526_003_0	11	8	$50 Copay	01	8b1;		2			1	50.00	50.00	2				2	
H1526	003	0	1	02	01	H1526_003_0	11	9	20% Coinsurance	11	8a1;8b2;9d;10a2;11a;11b;	9d_2;	1	20	20	2			2				2	
H1526	004	0	1	02	01	H1526_004_0	10	1	$0 Costshare	11	6;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;	13c;14b;14c1;14c4;14c6;14c8;14c10;14c11;14c13;14c14;14c20;14c21;	2			2			2				2	
H1526	004	0	1	02	01	H1526_004_0	10	2	20% Coinsurance	11	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;12;	7b;7f_2;9d_2;13a;	1	20	20	2			2				2	
H1526	004	0	1	02	01	H1526_004_0	10	3	0-20% Coinsurance; $35 Copay	01	15;		1	0	20	1	35.00	35.00	2				2	
H1526	004	0	1	02	01	H1526_004_0	10	4	$135 Per Month	10		13b;	2			2			1	135.00	7		2	
H1526	004	0	1	02	01	H1526_004_0	10	5	$3500 Flex Card	11	16b;17a;17b;18a;	16a;16b;17a;17b;18a;18a2;18b;	2			2			2				2	
H1526	005	0	1	02	01	H1526_005_0	13	1	$0 Costshare	11	6;7a;7f;8a2;8b3;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;	13c;14b;14c1;14c4;14c6;14c8;14c10;14c11;14c13;14c14;14c20;14c21;	2			2			2				2	
H1526	005	0	1	02	01	H1526_005_0	13	10	$200 Copay	01	10a1;		2			1	200.00	200.00	2				2	
H1526	005	0	1	02	01	H1526_005_0	13	11	$25 per month	10		13b;	2			2			1	25.00	7		2	
H1526	005	0	1	02	01	H1526_005_0	13	12	0-20% Coinsurance; $35 Copay	01	15;		1	0	20	1	35.00	35.00	2				2	
H1526	005	0	1	02	01	H1526_005_0	13	13	$125 Copay	01	9b;		2			1	125.00	125.00	2				2	
H1526	005	0	1	02	01	H1526_005_0	13	14	$1300 Flex Card	11	16b;17a;17b;18a;	16a;16b;17a;17b;18a;18a2;18b;	2			2			2				2	
H1526	005	0	1	02	01	H1526_005_0	13	15	$70 Copay	01	5;		2			1	70.00	70.00	2				2	
H1526	005	0	1	02	01	H1526_005_0	13	16	$0-225 Copay	01	9a1;		2			1	0.00	225.00	2				2	
H1526	005	0	1	02	01	H1526_005_0	13	2	$10 Copay	01	3-1;3-2;3-3;3-4;7c;7d;7g;7i;		2			1	10.00	10.00	2				2	
H1526	005	0	1	02	01	H1526_005_0	13	3	$20 Copay	11	7b;	7b;	2			1	20.00	20.00	2				2	
H1526	005	0	1	02	01	H1526_005_0	13	4	$10-25 Copay	01	7e;7h;		2			1	10.00	25.00	2				2	
H1526	005	0	1	02	01	H1526_005_0	13	5	$25 Copay	01	7k;		2			1	25.00	25.00	2				2	
H1526	005	0	1	02	01	H1526_005_0	13	6	$50 Copay	01	8a1;8b1;		2			1	50.00	50.00	2				2	
H1526	005	0	1	02	01	H1526_005_0	13	7	20% Coinsurance	11	8b2;9d;10a2;11a;12;	9d_2;13a;	1	20	20	2			2				2	
H1526	005	0	1	02	01	H1526_005_0	13	8	$175 Copay	01	9a2;		2			1	175.00	175.00	2				2	
H1526	005	0	1	02	01	H1526_005_0	13	9	$15-25 Copay	01	9c;		2			1	15.00	25.00	2				2	
H1526	006	0	1	02	01	H1526_006_0	11	1	$0 Costshare	11	6;7a;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;	13c;14b;14c6;14c10;14c11;14c13;14c14;14c21;	2			2			2				2	
H1526	006	0	1	02	01	H1526_006_0	11	2	$10 Copay	01	7d;7i;		2			1	10.00	10.00	2				2	
H1526	006	0	1	02	01	H1526_006_0	11	3	20% Coinsurance	11	3-1;3-2;3-3;3-4;5;7b;7c;7e;7f;7g;7h;7k;8a1;8a2;8b1;8b2;8b3;9c;9d;10a2;11a;11b;12;	9d_2;	1	20	20	2			2				2	
H1526	006	0	1	02	01	H1526_006_0	11	4	$175 Copay	01	9a1;9a2;		2			1	175.00	175.00	2				2	
H1526	006	0	1	02	01	H1526_006_0	11	5	$25 per month	10		13b;	2			2			1	25.00	7		2	
H1526	006	0	1	02	01	H1526_006_0	11	6	0-20% Coinsurance; $35 Copay	01	15;		1	0	20	1	35.00	35.00	2				2	
H1526	006	0	1	02	01	H1526_006_0	11	7	$ 2500 Flex Card	11	16b;17a;17b;18a;	16a;16b;17a;17b;18a;18a2;18b;	2			2			2				2	
H1526	006	0	1	02	01	H1526_006_0	11	8	$125 Copay	01	9b;		2			1	125.00	125.00	2				2	
H1526	006	0	1	02	01	H1526_006_0	11	9	$250 Copay	01	10a1;		2			1	250.00	250.00	2				2	
H1587	001	0	1	02	01	H1587_001_0	9	1	Non-contracted Providers	11	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	16a;16b;17a;17b;	1	20	20	2			2				2	
H1587	003	0	1	02	01	H1587_003_0	11	1	Non-contract Providers	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H1609	001	0	1	02	01	H1609_001_0	6	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H1609	028	0	1	02	01	H1609_028_0	6	1	$0 - $50 copay	01	7g;		2			1	0.00	50.00	2				2	
H1609	028	0	1	02	01	H1609_028_0	6	2	$0 copay	01	14a;		2			1	0.00	0.00	2				2	
H1609	028	0	1	02	01	H1609_028_0	6	3	$255 copay	01	10a1;		2			1	255.00	255.00	2				2	
H1609	028	0	1	02	01	H1609_028_0	6	4	$50 copay	01	7d;		2			1	50.00	50.00	2				2	
H1609	028	0	1	02	01	H1609_028_0	6	5	20% coinsurance	01	10a2;		1	20	20	2			2				2	
H1609	028	0	1	02	01	H1609_028_0	6	6	50% coinsurance	01	3-1;3-2;3-3;3-4;5;6;7b;7f;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;12;		1	50	50	2			2				2	
H1609	058	0	1	02	01	H1609_058_0	3	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H1609	068	0	1	02	01	H1609_068_0	6	1	$0 copay				2			1	0.00	0.00	2				2	
H1609	068	0	1	02	01	H1609_068_0	6	2	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H1609	069	0	1	02	01	H1609_069_0	6	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H1692	002	0	1	02	01	H1692_002_0	7	1	20% Coinsurance	10		16a;16b;	1	20	20	2			2				2	
H1692	003	0	1	02	01	H1692_003_0	6	1	50% Coinsurance	10		16a;16b;	1	50	50	2			2				2	
H1692	006	0	1	02	01	H1692_006_0	3	1	Dental	10		16a;16b;	1	50	50	2			2				2	
H1692	007	0	1	02	01	H1692_007_0	6	1	20% Coinsurance	10		16a;16b;	1	20	20	2			2				2	
H1822	005	0	1	02	01	H1822_005_0	6	1	$0	01	8a1;8a2;8b3;12;16b;17a;17b;18a;		2			2			2				2	
H1822	005	0	1	02	01	H1822_005_0	6	2	$10	01	7d;7e;7f;7g;7h;		2			1	10.00	10.00	2				2	
H1822	005	0	1	02	01	H1822_005_0	6	3	$0-$125	01	8b1;		2			1	0.00	125.00	2				2	
H1822	005	0	1	02	01	H1822_005_0	6	4	$60	01	8b2;		2			1	60.00	60.00	2				2	
H1944	001	0	1	02	01	H1944_001_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1944	001	0	1	02	01	H1944_001_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H1944	004	0	1	02	01	H1944_004_0	8	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1944	004	0	1	02	01	H1944_004_0	8	2	Group 2	10		16b;	1	0	50	2			2				2	
H1944	005	0	1	02	01	H1944_005_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1944	005	0	1	02	01	H1944_005_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H1944	006	0	1	02	01	H1944_006_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1944	009	0	1	02	01	H1944_009_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1944	009	0	1	02	01	H1944_009_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H1944	010	0	1	02	01	H1944_010_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1944	010	0	1	02	01	H1944_010_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H1944	011	0	1	02	01	H1944_011_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1944	011	0	1	02	01	H1944_011_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H1944	014	0	1	02	01	H1944_014_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1944	014	0	1	02	01	H1944_014_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H1944	015	0	1	02	01	H1944_015_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1944	015	0	1	02	01	H1944_015_0	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H1944	016	0	1	02	01	H1944_016_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1944	016	0	1	02	01	H1944_016_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H1944	017	0	1	02	01	H1944_017_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1944	017	0	1	02	01	H1944_017_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H1944	018	0	1	02	01	H1944_018_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1944	018	0	1	02	01	H1944_018_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H1944	024	0	1	02	01	H1944_024_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1944	024	0	1	02	01	H1944_024_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H1944	030	0	1	02	01	H1944_030_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1944	030	0	1	02	01	H1944_030_0	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H1944	031	0	1	02	01	H1944_031_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1944	031	0	1	02	01	H1944_031_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H1944	032	0	1	02	01	H1944_032_0	7	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1944	032	0	1	02	01	H1944_032_0	7	2	Group 2	10		16b;	1	0	50	2			2				2	
H1944	033	0	1	02	01	H1944_033_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1944	033	0	1	02	01	H1944_033_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H1944	034	0	1	02	01	H1944_034_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1944	034	0	1	02	01	H1944_034_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H1944	035	0	1	02	01	H1944_035_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1944	035	0	1	02	01	H1944_035_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H1961	003	0	1	02	01	H1961_003_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1961	003	0	1	02	01	H1961_003_0	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H1961	014	1	1	02	01	H1961_014_1	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1961	014	1	1	02	01	H1961_014_1	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H1961	014	2	1	02	01	H1961_014_2	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1961	014	2	1	02	01	H1961_014_2	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H1961	014	3	1	02	01	H1961_014_3	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1961	014	3	1	02	01	H1961_014_3	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H1961	014	4	1	02	01	H1961_014_4	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1961	014	4	1	02	01	H1961_014_4	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H1961	017	0	1	02	01	H1961_017_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1961	017	0	1	02	01	H1961_017_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H1961	019	0	1	02	01	H1961_019_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H1961	020	0	1	02	01	H1961_020_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H1961	020	0	1	02	01	H1961_020_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H1961	801	0	1	02	01	H1961_801_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H1961	801	0	1	02	01	H1961_801_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H1961	802	0	1	02	01	H1961_802_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H1961	802	0	1	02	01	H1961_802_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H2056	001	0	1	02	01	H2056_001_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H2056	002	0	1	02	01	H2056_002_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H2056	003	0	1	02	01	H2056_003_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H2056	004	0	1	02	01	H2056_004_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H2056	005	0	1	02	01	H2056_005_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H2056	010	0	1	02	01	H2056_010_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H2056	011	0	1	02	01	H2056_011_0	8	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H2056	012	0	1	02	01	H2056_012_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H2056	013	0	1	02	01	H2056_013_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H2172	001	0	1	02	01	H2172_001_0	9	1	Part B Drugs	01	15;		1	20	20	2			2				2	
H2172	001	0	1	02	01	H2172_001_0	9	2	Healthcare Professional Services	01	3-1;3-2;7b;7c;7d;7f;7i;17a;18a;		2			1	0.00	50.00	2				2	
H2172	001	0	1	02	01	H2172_001_0	9	3	Outpatient Tests and Services	11	8a1;8a2;8b1;8b3;9d;14e5;	9d_2;	2			1	0.00	25.00	2				2	
H2172	001	0	1	02	01	H2172_001_0	9	4	Primary and Preventative Care	11	7a;14a;14e1;14e3;14e4;	14b;	2			1	0.00	25.00	2				2	
H2172	001	0	1	02	01	H2172_001_0	9	5	Behavioral Health Care	01	7e;7h;9c;		2			1	15.00	25.00	2				2	
H2172	002	0	1	02	01	H2172_002_0	10	1	Part B Drugs	01	15;		1	20	20	2			2				2	
H2172	002	0	1	02	01	H2172_002_0	10	2	Healthcare Professional Services	01	3-1;3-2;7b;7c;7d;7f;7i;17a;18a;		2			1	0.00	50.00	2				2	
H2172	002	0	1	02	01	H2172_002_0	10	3	Outpatient Tests and Services	11	8a1;8a2;8b1;8b3;9d;14e5;	9d_2;	2			1	0.00	25.00	2				2	
H2172	002	0	1	02	01	H2172_002_0	10	4	Primary and Preventative Care	11	7a;14a;14e1;14e3;14e4;	14b;	2			1	0.00	25.00	2				2	
H2172	002	0	1	02	01	H2172_002_0	10	5	Behavioral Health Care	01	7e;7h;9c;		2			1	15.00	25.00	2				2	
H2172	003	0	1	02	01	H2172_003_0	9	1	Part B Drugs	01	15;		1	20	20	2			2				2	
H2172	003	0	1	02	01	H2172_003_0	9	2	Healthcare Professional Services	01	3-1;3-2;7b;7c;7d;7f;7i;17a;18a;		2			1	0.00	50.00	2				2	
H2172	003	0	1	02	01	H2172_003_0	9	3	Outpatient Tests and Services	11	8a1;8a2;8b1;8b3;9d;14e5;	9d_2;	2			1	0.00	25.00	2				2	
H2172	003	0	1	02	01	H2172_003_0	9	4	Primary and Preventative Care	11	7a;14a;14e1;14e3;14e4;	14b;	2			1	0.00	25.00	2				2	
H2172	003	0	1	02	01	H2172_003_0	9	5	Behavioral Health Care	01	7e;7h;9c;		2			1	15.00	25.00	2				2	
H2172	004	0	1	02	01	H2172_004_0	10	1	Part B Drugs	01	15;		1	20	20	2			2				2	
H2172	004	0	1	02	01	H2172_004_0	10	2	Healthcare Professional Services	01	3-1;3-2;7b;7c;7d;7f;7i;17a;18a;		2			1	0.00	50.00	2				2	
H2172	004	0	1	02	01	H2172_004_0	10	3	Outpatient Tests and Services	11	8a1;8a2;8b1;8b3;9d;14e5;	9d_2;	2			1	0.00	25.00	2				2	
H2172	004	0	1	02	01	H2172_004_0	10	4	Primary and Preventative Care	11	7a;14a;14e1;14e3;14e4;	14b;	2			1	0.00	25.00	2				2	
H2172	004	0	1	02	01	H2172_004_0	10	5	Behavioral Health Care	01	7e;7h;9c;		2			1	15.00	25.00	2				2	
H2172	008	0	1	02	01	H2172_008_0	9	1	Part B Drugs	01	15;		1	20	20	2			2				2	
H2172	008	0	1	02	01	H2172_008_0	9	2	Healthcare Professional Services	01	3-1;3-2;7b;7c;7d;7f;7i;17a;18a;		2			1	0.00	50.00	2				2	
H2172	008	0	1	02	01	H2172_008_0	9	3	Outpatient Tests and Services	11	8a1;8a2;8b1;8b3;9d;14e5;	9d_2;	2			1	0.00	25.00	2				2	
H2172	008	0	1	02	01	H2172_008_0	9	4	Primary and Preventative Care	11	7a;14a;14e1;14e3;14e4;	14b;	2			1	0.00	25.00	2				2	
H2172	008	0	1	02	01	H2172_008_0	9	5	Behavioral Health Care	01	7e;7h;9c;		2			1	15.00	25.00	2				2	
H2172	009	0	1	02	01	H2172_009_0	9	1	Part B Drugs	01	15;		1	20	20	2			2				2	
H2172	009	0	1	02	01	H2172_009_0	9	2	Healthcare Professional Services	01	3-1;3-2;7b;7c;7d;7f;7i;17a;18a;		2			1	0.00	50.00	2				2	
H2172	009	0	1	02	01	H2172_009_0	9	3	Outpatient Tests and Services	11	8a1;8a2;8b1;8b3;9d;14e5;	9d_2;	2			1	0.00	25.00	2				2	
H2172	009	0	1	02	01	H2172_009_0	9	4	Primary and Preventative Care	11	7a;14a;14e1;14e3;14e4;	14b;	2			1	0.00	25.00	2				2	
H2172	009	0	1	02	01	H2172_009_0	9	5	Behavioral Health Care	01	7e;7h;9c;		2			1	15.00	25.00	2				2	
H2172	010	0	1	02	01	H2172_010_0	9	1	Part B Drugs	01	15;		1	20	20	2			2				2	
H2172	010	0	1	02	01	H2172_010_0	9	2	Healthcare Professional Services	01	3-1;3-2;7b;7c;7d;7f;7i;17a;18a;		2			1	0.00	50.00	2				2	
H2172	010	0	1	02	01	H2172_010_0	9	3	Outpatient Tests and Services	11	8a1;8a2;8b1;8b3;9d;14e5;	9d_2;	2			1	0.00	25.00	2				2	
H2172	010	0	1	02	01	H2172_010_0	9	4	Primary and Preventative Care	11	7a;14a;14e1;14e3;14e4;	14b;	2			1	0.00	25.00	2				2	
H2172	010	0	1	02	01	H2172_010_0	9	5	Behavioral Health Care	01	7e;7h;9c;		2			1	15.00	25.00	2				2	
H2172	012	0	1	02	01	H2172_012_0	9	1	Part B Drugs	01	15;		1	20	20	2			2				2	
H2172	012	0	1	02	01	H2172_012_0	9	2	Healthcare Professional Services	01	3-1;3-2;7b;7c;7d;7f;7i;17a;18a;		2			1	0.00	50.00	2				2	
H2172	012	0	1	02	01	H2172_012_0	9	3	Outpatient Tests and Services	11	8a1;8a2;8b1;8b3;9d;14e5;	9d_2;	2			1	0.00	25.00	2				2	
H2172	012	0	1	02	01	H2172_012_0	9	4	Primary and Preventative Care	11	7a;14a;14e1;14e3;14e4;	14b;	2			1	0.00	25.00	2				2	
H2172	012	0	1	02	01	H2172_012_0	9	5	Behavioral Health Care	01	7e;7h;9c;		2			1	15.00	25.00	2				2	
H2172	013	0	1	02	01	H2172_013_0	9	1	Part B Drugs	01	15;		1	20	20	2			2				2	
H2172	013	0	1	02	01	H2172_013_0	9	2	Healthcare Professional Services	01	3-1;3-2;7b;7c;7d;7f;7i;17a;18a;		2			1	0.00	50.00	2				2	
H2172	013	0	1	02	01	H2172_013_0	9	3	Outpatient Tests and Services	11	8a1;8a2;8b1;8b3;9d;14e5;	9d_2;	2			1	0.00	50.00	2				2	
H2172	013	0	1	02	01	H2172_013_0	9	4	Primary and Preventative Care	11	7a;14a;14e1;14e3;14e4;	14b;	2			1	0.00	25.00	2				2	
H2172	013	0	1	02	01	H2172_013_0	9	5	Behavioral Health Care	01	7e;7h;9c;		2			1	15.00	25.00	2				2	
H2185	003	0	1	02	01	H2185_003_0	8	1	$0 Copay Group	01	7a;8a2;8b3;		2			2			2				2	
H2185	003	0	1	02	01	H2185_003_0	8	2	$10 Copay Group	01	7d;		2			1	10.00	10.00	2				2	
H2185	003	0	1	02	01	H2185_003_0	8	3	$100 Copay Group	01	9a2;		2			1	100.00	100.00	2				2	
H2185	003	0	1	02	01	H2185_003_0	8	4	20% Coinsurance Group	01	8a1;8b1;8b2;9a1;9b;		1	20	20	2			2				2	
H2235	006	0	1	02	01	H2235_006_0	15	1	Primary Care - Out of Network	01	7a;		2			1	50.00	50.00	2				2	
H2235	006	0	1	02	01	H2235_006_0	15	2	Specialist - Out of Network	01	7b;7c;7d;7e;7f;7g;7h;7i;7k;9c;16b;17a;17b;18a;		2			1	70.00	70.00	2				2	
H2235	006	0	1	02	01	H2235_006_0	15	3	Other - Out of Network Coinsurance	11	3-1;3-2;3-3;3-4;5;6;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;	9d_2;	1	45	45	2			2				2	
H2247	001	0	1	02	01	H2247_001_0	3	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H2247	003	0	1	02	01	H2247_003_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2247	003	0	1	02	01	H2247_003_0	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H2261	023	1	1	02	01	H2261_023_1	6	1	Group #1	11	3-1;3-2;3-3;3-4;5;6;7c;7e;7h;7i;8a1;8a2;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14d;	9d_2;15;	1	20	20	2			2				2	
H2261	023	1	1	02	01	H2261_023_1	6	10	Group #10	01	15;		1	20	20	2			2				2	
H2261	023	1	1	02	01	H2261_023_1	6	2	Group #2	10		16a;	2			1	45.00	45.00	2				2	
H2261	023	1	1	02	01	H2261_023_1	6	3	Group #3	01	10a1;10a2;		2			1	100.00	100.00	2				2	
H2261	023	1	1	02	01	H2261_023_1	6	4	Group #4	11	7k;17b;	14c1;14c5;14c7;	2			2			2				2	
H2261	023	1	1	02	01	H2261_023_1	6	5	Group #5	10		14c4;14c16;	2			2			1	150.00	3		2	
H2261	023	1	1	02	01	H2261_023_1	6	6	Group #6	10		14c15;	2			2			1	500.00	3		2	
H2261	023	1	1	02	01	H2261_023_1	6	7	Group #7	01	14a;14e1;14e2;14e3;14e4;14e5;16b;		1	20	20	1	65.00	65.00	2				2	
H2261	023	1	1	02	01	H2261_023_1	6	8	Group #8	01	8b1;		1	40	40	2			2				2	
H2261	023	1	1	02	01	H2261_023_1	6	9	Group #9	11	7a;7b;7d;7f;7g;17a;18a;	14b;	2			1	65.00	65.00	2				2	
H2261	023	2	1	02	01	H2261_023_2	6	1	Group #1	11	3-1;3-2;3-3;3-4;5;6;7c;7e;7h;7i;8a1;8a2;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14d;	9d_2;15;	1	20	20	2			2				2	
H2261	023	2	1	02	01	H2261_023_2	6	10	Group #10	01	15;		1	20	20	2			2				2	
H2261	023	2	1	02	01	H2261_023_2	6	2	Group #2	10		16a;	2			1	45.00	45.00	2				2	
H2261	023	2	1	02	01	H2261_023_2	6	3	Group #3	01	10a1;10a2;		2			1	100.00	100.00	2				2	
H2261	023	2	1	02	01	H2261_023_2	6	4	Group #4	11	7k;17b;	14c1;14c5;14c7;	2			2			2				2	
H2261	023	2	1	02	01	H2261_023_2	6	5	Group #5	10		14c4;14c16;	2			2			1	150.00	3		2	
H2261	023	2	1	02	01	H2261_023_2	6	6	Group #6	10		14c15;	2			2			1	500.00	3		2	
H2261	023	2	1	02	01	H2261_023_2	6	7	Group #7	01	14a;14e1;14e2;14e3;14e4;14e5;16b;		1	20	20	1	65.00	65.00	2				2	
H2261	023	2	1	02	01	H2261_023_2	6	8	Group #8	01	8b1;		1	40	40	2			2				2	
H2261	023	2	1	02	01	H2261_023_2	6	9	Group #9	11	7a;7b;7d;7f;7g;17a;18a;	14b;	2			1	65.00	65.00	2				2	
H2272	001	0	1	02	01	H2272_001_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2272	001	0	1	02	01	H2272_001_0	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H2320	022	1	1	02	01	H2320_022_1	6	1	50% Coinsurance	11	3-1;3-2;3-3;3-4;7a;7b;7c;7d;7e;7f;7h;7i;7k;8a1;8b1;8b2;8b3;9a1;9b;9c;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	13e;14b;	1	50	50	2			2				2	
H2320	022	1	1	02	01	H2320_022_1	6	10	8a2 Lab Services	01	8a2;		1	0	50	2			2				2	
H2320	022	1	1	02	01	H2320_022_1	6	11	Acupuncture	10		13a;	2			1	20.00	20.00	2				2	
H2320	022	1	1	02	01	H2320_022_1	6	12	7G	01	7g;		1	50	50	1	20.00	20.00	2				2	
H2320	022	1	1	02	01	H2320_022_1	6	13	Embedded dental 16a and 16b	10		16a;16b;	2			2			2				2	
H2320	022	1	1	02	01	H2320_022_1	6	2	30% Coinsurance	01	11a;11b;		1	30	30	2			2				2	
H2320	022	1	1	02	01	H2320_022_1	6	3	Part B Drugs	01	15;		1	0	20	2			2				2	
H2320	022	1	1	02	01	H2320_022_1	6	4	$0 Copayment	11	6;9d;	9d_2;15;	2			2			2				2	
H2320	022	1	1	02	01	H2320_022_1	6	5	$270 Copayment	11	10a1;10a2;	13d;	2			1	270.00	270.00	2				2	
H2320	022	1	1	02	01	H2320_022_1	6	6	40% Coinsurance	01	5;		1	40	40	2			2				2	
H2320	022	1	1	02	01	H2320_022_1	6	7	$120 copayment	01	9a2;		2			1	120.00	120.00	2				2	
H2320	022	1	1	02	01	H2320_022_1	6	8	Embedded Vision 17a	10		17a;	2			2			2				2	
H2320	022	1	1	02	01	H2320_022_1	6	9	17b Eyewear	10		17b;	2			2			1	100.00	3		2	
H2320	022	2	1	02	01	H2320_022_2	6	1	50% Coinsurance	11	3-1;3-2;3-3;3-4;7a;7b;7c;7d;7e;7f;7h;7i;7k;8a1;8b1;8b2;8b3;9a1;9b;9c;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	13e;14b;	1	50	50	2			2				2	
H2320	022	2	1	02	01	H2320_022_2	6	10	8a2 Lab Services	01	8a2;		1	0	50	2			2				2	
H2320	022	2	1	02	01	H2320_022_2	6	11	Acupuncture	10		13a;	2			1	20.00	20.00	2				2	
H2320	022	2	1	02	01	H2320_022_2	6	12	7G	01	7g;		1	50	50	1	20.00	20.00	2				2	
H2320	022	2	1	02	01	H2320_022_2	6	13	Embedded dental 16a and 16b	10		16a;16b;	2			2			2				2	
H2320	022	2	1	02	01	H2320_022_2	6	2	30% Coinsurance	01	11a;11b;		1	30	30	2			2				2	
H2320	022	2	1	02	01	H2320_022_2	6	3	Part B Drugs	01	15;		1	0	20	2			2				2	
H2320	022	2	1	02	01	H2320_022_2	6	4	$0 Copayment	11	6;9d;	9d_2;15;	2			2			2				2	
H2320	022	2	1	02	01	H2320_022_2	6	5	$270 Copayment	11	10a1;10a2;	13d;	2			1	270.00	270.00	2				2	
H2320	022	2	1	02	01	H2320_022_2	6	6	40% Coinsurance	01	5;		1	40	40	2			2				2	
H2320	022	2	1	02	01	H2320_022_2	6	7	$120 copayment	01	9a2;		2			1	120.00	120.00	2				2	
H2320	022	2	1	02	01	H2320_022_2	6	8	Embedded Vision 17a	10		17a;	2			2			2				2	
H2320	022	2	1	02	01	H2320_022_2	6	9	17b Eyewear	10		17b;	2			2			1	100.00	3		2	
H2320	022	3	1	02	01	H2320_022_3	6	1	50% Coinsurance	11	3-1;3-2;3-3;3-4;7a;7b;7c;7d;7e;7f;7h;7i;7k;8a1;8b1;8b2;8b3;9a1;9b;9c;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	13e;14b;	1	50	50	2			2				2	
H2320	022	3	1	02	01	H2320_022_3	6	10	8a2 Lab Services	01	8a2;		1	0	50	2			2				2	
H2320	022	3	1	02	01	H2320_022_3	6	11	Acupuncture	10		13a;	2			1	20.00	20.00	2				2	
H2320	022	3	1	02	01	H2320_022_3	6	12	7G	01	7g;		1	50	50	1	20.00	20.00	2				2	
H2320	022	3	1	02	01	H2320_022_3	6	13	Embedded dental 16a and 16b	10		16a;16b;	2			2			2				2	
H2320	022	3	1	02	01	H2320_022_3	6	2	30% Coinsurance	01	11a;11b;		1	30	30	2			2				2	
H2320	022	3	1	02	01	H2320_022_3	6	3	Part B Drugs	01	15;		1	0	20	2			2				2	
H2320	022	3	1	02	01	H2320_022_3	6	4	$0 Copayment	11	6;9d;	9d_2;15;	2			2			2				2	
H2320	022	3	1	02	01	H2320_022_3	6	5	$270 Copayment	11	10a1;10a2;	13d;	2			1	270.00	270.00	2				2	
H2320	022	3	1	02	01	H2320_022_3	6	6	40% Coinsurance	01	5;		1	40	40	2			2				2	
H2320	022	3	1	02	01	H2320_022_3	6	7	$120 copayment	01	9a2;		2			1	120.00	120.00	2				2	
H2320	022	3	1	02	01	H2320_022_3	6	8	Embedded Vision 17a	10		17a;	2			2			2				2	
H2320	022	3	1	02	01	H2320_022_3	6	9	17b Eyewear	10		17b;	2			2			1	100.00	3		2	
H2320	022	4	1	02	01	H2320_022_4	6	1	50% Coinsurance	11	3-1;3-2;3-3;3-4;7a;7b;7c;7d;7e;7f;7h;7i;7k;8a1;8b1;8b2;8b3;9a1;9b;9c;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	13e;14b;	1	50	50	2			2				2	
H2320	022	4	1	02	01	H2320_022_4	6	10	8a2 Lab Services	01	8a2;		1	0	50	2			2				2	
H2320	022	4	1	02	01	H2320_022_4	6	11	Acupuncture	10		13a;	2			1	20.00	20.00	2				2	
H2320	022	4	1	02	01	H2320_022_4	6	12	7G	01	7g;		1	50	50	1	20.00	20.00	2				2	
H2320	022	4	1	02	01	H2320_022_4	6	13	Embedded dental 16a and 16b	10		16a;16b;	2			2			2				2	
H2320	022	4	1	02	01	H2320_022_4	6	2	30% Coinsurance	01	11a;11b;		1	30	30	2			2				2	
H2320	022	4	1	02	01	H2320_022_4	6	3	Part B Drugs	01	15;		1	0	20	2			2				2	
H2320	022	4	1	02	01	H2320_022_4	6	4	$0 Copayment	11	6;9d;	9d_2;15;	2			2			2				2	
H2320	022	4	1	02	01	H2320_022_4	6	5	$270 Copayment	11	10a1;10a2;	13d;	2			1	270.00	270.00	2				2	
H2320	022	4	1	02	01	H2320_022_4	6	6	40% Coinsurance	01	5;		1	40	40	2			2				2	
H2320	022	4	1	02	01	H2320_022_4	6	7	$120 copayment	01	9a2;		2			1	120.00	120.00	2				2	
H2320	022	4	1	02	01	H2320_022_4	6	8	Embedded Vision 17a	10		17a;	2			2			2				2	
H2320	022	4	1	02	01	H2320_022_4	6	9	17b Eyewear	10		17b;	2			2			1	100.00	3		2	
H2320	022	5	1	02	01	H2320_022_5	6	1	50% Coinsurance	11	3-1;3-2;3-3;3-4;7a;7b;7c;7d;7e;7f;7h;7i;7k;8a1;8b1;8b2;8b3;9a1;9b;9c;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	13e;14b;	1	50	50	2			2				2	
H2320	022	5	1	02	01	H2320_022_5	6	10	8a2 Lab Services	01	8a2;		1	0	50	2			2				2	
H2320	022	5	1	02	01	H2320_022_5	6	11	Acupuncture	10		13a;	2			1	20.00	20.00	2				2	
H2320	022	5	1	02	01	H2320_022_5	6	12	7G	01	7g;		1	50	50	1	20.00	20.00	2				2	
H2320	022	5	1	02	01	H2320_022_5	6	13	Embedded Dental 16a and 16b	10		16a;16b;	2			2			2				2	
H2320	022	5	1	02	01	H2320_022_5	6	2	30% Coinsurance	01	11a;11b;		1	30	30	2			2				2	
H2320	022	5	1	02	01	H2320_022_5	6	3	Part B Drugs	01	15;		1	0	20	2			2				2	
H2320	022	5	1	02	01	H2320_022_5	6	4	$0 Copayment	11	6;9d;	9d_2;15;	2			2			2				2	
H2320	022	5	1	02	01	H2320_022_5	6	5	$270 Copayment	11	10a1;10a2;	13d;	2			1	270.00	270.00	2				2	
H2320	022	5	1	02	01	H2320_022_5	6	6	40% Coinsurance	01	5;		1	40	40	2			2				2	
H2320	022	5	1	02	01	H2320_022_5	6	7	$120 copayment	01	9a2;		2			1	120.00	120.00	2				2	
H2320	022	5	1	02	01	H2320_022_5	6	8	Embedded Vision 17a	10		17a;	2			2			2				2	
H2320	022	5	1	02	01	H2320_022_5	6	9	17b Eyewear	10		17b;	2			2			1	100.00	3		2	
H2320	028	1	1	02	01	H2320_028_1	6	1	30% Coinsurance	11	3-1;3-2;3-3;3-4;7a;7b;7c;7d;7e;7f;7h;7i;7k;8a1;8b1;8b2;8b3;9a1;9b;9c;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	13e;14b;	1	30	30	2			2				2	
H2320	028	1	1	02	01	H2320_028_1	6	10	Routine Acupuncture	10		13a;	2			1	20.00	20.00	2				2	
H2320	028	1	1	02	01	H2320_028_1	6	11	7G	01	7g;		1	30	30	1	20.00	20.00	2				2	
H2320	028	1	1	02	01	H2320_028_1	6	12	Embedded dental 16a and 16b	10		16a;16b;	2			2			2				2	
H2320	028	1	1	02	01	H2320_028_1	6	2	Part B Drugs	01	15;		1	0	20	2			2				2	
H2320	028	1	1	02	01	H2320_028_1	6	3	40% coinsurance	01	5;		1	40	40	2			2				2	
H2320	028	1	1	02	01	H2320_028_1	6	4	$0 Copayment	11	6;9d;	9d_2;15;	2			2			2				2	
H2320	028	1	1	02	01	H2320_028_1	6	5	$210 Copayment	11	10a1;10a2;	13d;	2			1	210.00	210.00	2				2	
H2320	028	1	1	02	01	H2320_028_1	6	6	$120 Copayment	01	9a2;		2			1	120.00	120.00	2				2	
H2320	028	1	1	02	01	H2320_028_1	6	7	17a Eye Exams	10		17a;	2			2			2				2	
H2320	028	1	1	02	01	H2320_028_1	6	8	17b Eyewear	10		17b;	2			2			1	100.00	3		2	
H2320	028	1	1	02	01	H2320_028_1	6	9	8a2 Lab Services	01	8a2;		1	0	30	2			2				2	
H2320	028	2	1	02	01	H2320_028_2	6	1	30% Coinsurance	11	3-1;3-2;3-3;3-4;7a;7b;7c;7d;7e;7f;7h;7i;7k;8a1;8b1;8b2;8b3;9a1;9b;9c;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	13e;14b;	1	30	30	2			2				2	
H2320	028	2	1	02	01	H2320_028_2	6	10	Routine Acupuncture	10		13a;	2			1	20.00	20.00	2				2	
H2320	028	2	1	02	01	H2320_028_2	6	11	7G	01	7g;		1	30	30	1	20.00	20.00	2				2	
H2320	028	2	1	02	01	H2320_028_2	6	12	Embedded dental 16a and 16b	10		16a;16b;	2			2			2				2	
H2320	028	2	1	02	01	H2320_028_2	6	2	Part B Drugs	01	15;		1	0	20	2			2				2	
H2320	028	2	1	02	01	H2320_028_2	6	3	40% coinsurance	01	5;		1	40	40	2			2				2	
H2320	028	2	1	02	01	H2320_028_2	6	4	$0 Copayment	11	6;9d;	9d_2;15;	2			2			2				2	
H2320	028	2	1	02	01	H2320_028_2	6	5	$210 Copayment	11	10a1;10a2;	13d;	2			1	210.00	210.00	2				2	
H2320	028	2	1	02	01	H2320_028_2	6	6	$120 Copayment	01	9a2;		2			1	120.00	120.00	2				2	
H2320	028	2	1	02	01	H2320_028_2	6	7	17a Eye Exams	10		17a;	2			2			2				2	
H2320	028	2	1	02	01	H2320_028_2	6	8	17b Eyewear	10		17b;	2			2			1	100.00	3		2	
H2320	028	2	1	02	01	H2320_028_2	6	9	8a2 Lab Services	01	8a2;		1	0	30	2			2				2	
H2320	028	3	1	02	01	H2320_028_3	6	1	30% Coinsurance	11	3-1;3-2;3-3;3-4;7a;7b;7c;7d;7e;7f;7h;7i;7k;8a1;8b1;8b2;8b3;9a1;9b;9c;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	13e;14b;	1	30	30	2			2				2	
H2320	028	3	1	02	01	H2320_028_3	6	10	Routine Acupuncture	10		13a;	2			1	20.00	20.00	2				2	
H2320	028	3	1	02	01	H2320_028_3	6	11	7G	01	7g;		1	30	30	1	20.00	20.00	2				2	
H2320	028	3	1	02	01	H2320_028_3	6	12	Embedded dental 16a and 16b	10		16a;16b;	2			2			2				2	
H2320	028	3	1	02	01	H2320_028_3	6	2	Part B Drugs	01	15;		1	0	20	2			2				2	
H2320	028	3	1	02	01	H2320_028_3	6	3	40% coinsurance	01	5;		1	40	40	2			2				2	
H2320	028	3	1	02	01	H2320_028_3	6	4	$0 Copayment	11	6;9d;	9d_2;15;	2			2			2				2	
H2320	028	3	1	02	01	H2320_028_3	6	5	$210 Copayment	11	10a1;10a2;	13d;	2			1	210.00	210.00	2				2	
H2320	028	3	1	02	01	H2320_028_3	6	6	$120 Copayment	01	9a2;		2			1	120.00	120.00	2				2	
H2320	028	3	1	02	01	H2320_028_3	6	7	17a Eye Exams	10		17a;	2			2			2				2	
H2320	028	3	1	02	01	H2320_028_3	6	8	17b Eyewear	10		17b;	2			2			1	100.00	3		2	
H2320	028	3	1	02	01	H2320_028_3	6	9	8a2 Lab Services	01	8a2;		1	0	30	2			2				2	
H2320	028	4	1	02	01	H2320_028_4	6	1	30% Coinsurance	11	3-1;3-2;3-3;3-4;7a;7b;7c;7d;7e;7f;7h;7i;7k;8a1;8b1;8b2;8b3;9a1;9b;9c;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	13e;14b;	1	30	30	2			2				2	
H2320	028	4	1	02	01	H2320_028_4	6	10	Routine Acupuncture	10		13a;	2			1	20.00	20.00	2				2	
H2320	028	4	1	02	01	H2320_028_4	6	11	7G	01	7g;		1	30	30	1	20.00	20.00	2				2	
H2320	028	4	1	02	01	H2320_028_4	6	12	Embedded dental 16a and 16b	10		16a;16b;	2			2			2				2	
H2320	028	4	1	02	01	H2320_028_4	6	2	Part B Drugs	01	15;		1	0	20	2			2				2	
H2320	028	4	1	02	01	H2320_028_4	6	3	40% coinsurance	01	5;		1	40	40	2			2				2	
H2320	028	4	1	02	01	H2320_028_4	6	4	$0 Copayment	11	6;9d;	9d_2;15;	2			2			2				2	
H2320	028	4	1	02	01	H2320_028_4	6	5	$210 Copayment	11	10a1;10a2;	13d;	2			1	210.00	210.00	2				2	
H2320	028	4	1	02	01	H2320_028_4	6	6	$120 Copayment	01	9a2;		2			1	120.00	120.00	2				2	
H2320	028	4	1	02	01	H2320_028_4	6	7	17a Eye Exams	10		17a;	2			2			2				2	
H2320	028	4	1	02	01	H2320_028_4	6	8	17b Eyewear	10		17b;	2			2			1	100.00	3		2	
H2320	028	4	1	02	01	H2320_028_4	6	9	8a2 Lab Services	01	8a2;		1	0	30	2			2				2	
H2320	028	5	1	02	01	H2320_028_5	6	1	30% Coinsurance	11	3-1;3-2;3-3;3-4;7a;7b;7c;7d;7e;7f;7h;7i;7k;8a1;8b1;8b2;8b3;9a1;9b;9c;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	13e;14b;	1	30	30	2			2				2	
H2320	028	5	1	02	01	H2320_028_5	6	10	Routine Acupuncture	10		13a;	2			1	20.00	20.00	2				2	
H2320	028	5	1	02	01	H2320_028_5	6	11	7G	01	7g;		1	30	30	1	20.00	20.00	2				2	
H2320	028	5	1	02	01	H2320_028_5	6	12	Embedded dental 16a and 16b	10		16a;16b;	2			2			2				2	
H2320	028	5	1	02	01	H2320_028_5	6	2	Part B Drugs	01	15;		1	0	20	2			2				2	
H2320	028	5	1	02	01	H2320_028_5	6	3	40% coinsurance	01	5;		1	40	40	2			2				2	
H2320	028	5	1	02	01	H2320_028_5	6	4	$0 Copayment	11	6;9d;	9d_2;15;	2			2			2				2	
H2320	028	5	1	02	01	H2320_028_5	6	5	$210 Copayment	11	10a1;10a2;	13d;	2			1	210.00	210.00	2				2	
H2320	028	5	1	02	01	H2320_028_5	6	6	$120 Copayment	01	9a2;		2			1	120.00	120.00	2				2	
H2320	028	5	1	02	01	H2320_028_5	6	7	17a Eye Exams	10		17a;	2			2			2				2	
H2320	028	5	1	02	01	H2320_028_5	6	8	17b Eyewear	10		17b;	2			2			1	100.00	3		2	
H2320	028	5	1	02	01	H2320_028_5	6	9	8a2 Lab Services	01	8a2;		1	0	30	2			2				2	
H2320	029	1	1	02	01	H2320_029_1	6	1	40% Coinsurance	11	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7h;7i;7k;8a1;8b1;8b2;8b3;9a1;9b;9c;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	13e;14b;	1	40	40	2			2				2	
H2320	029	1	1	02	01	H2320_029_1	6	10	Acupuncture	10		13a;	2			1	20.00	20.00	2				2	
H2320	029	1	1	02	01	H2320_029_1	6	11	7G	01	7g;		1	40	40	1	20.00	20.00	2				2	
H2320	029	1	1	02	01	H2320_029_1	6	12	Embedded Dental 16a and 16b	10		16a;16b;	2			2			2				2	
H2320	029	1	1	02	01	H2320_029_1	6	2	Part B Drugs	01	15;		1	0	20	2			2				2	
H2320	029	1	1	02	01	H2320_029_1	6	3	$0 Copayment	11	6;9d;	9d_2;15;	2			2			2				2	
H2320	029	1	1	02	01	H2320_029_1	6	4	$265 Copayment	11	10a1;10a2;	13d;	2			1	265.00	265.00	2				2	
H2320	029	1	1	02	01	H2320_029_1	6	5	30% Coinsurance	01	11a;11b;		1	30	30	2			2				2	
H2320	029	1	1	02	01	H2320_029_1	6	6	$120 copayment	01	9a2;		2			1	120.00	120.00	2				2	
H2320	029	1	1	02	01	H2320_029_1	6	7	17a Eye Exams	10		17a;	2			2			2				2	
H2320	029	1	1	02	01	H2320_029_1	6	8	17b Eyewear	10		17b;	2			2			1	100.00	3		2	
H2320	029	1	1	02	01	H2320_029_1	6	9	8a2 Lab Services	01	8a2;		1	0	40	2			2				2	
H2320	029	2	1	02	01	H2320_029_2	6	1	40% Coinsurance	11	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7h;7i;7k;8a1;8b1;8b2;8b3;9a1;9b;9c;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	13e;14b;	1	40	40	2			2				2	
H2320	029	2	1	02	01	H2320_029_2	6	10	Acupuncture	10		13a;	2			1	20.00	20.00	2				2	
H2320	029	2	1	02	01	H2320_029_2	6	11	7G	01	7g;		1	40	40	1	20.00	20.00	2				2	
H2320	029	2	1	02	01	H2320_029_2	6	12	Embedded Dental 16a and 16b	10		16a;16b;	2			2			2				2	
H2320	029	2	1	02	01	H2320_029_2	6	2	Part B Drugs	01	15;		1	0	20	2			2				2	
H2320	029	2	1	02	01	H2320_029_2	6	3	$0 Copayment	11	6;9d;	9d_2;15;	2			2			2				2	
H2320	029	2	1	02	01	H2320_029_2	6	4	$265 Copayment	11	10a1;10a2;	13d;	2			1	265.00	265.00	2				2	
H2320	029	2	1	02	01	H2320_029_2	6	5	30% Coinsurance	01	11a;11b;		1	30	30	2			2				2	
H2320	029	2	1	02	01	H2320_029_2	6	6	$120 copayment	01	9a2;		2			1	120.00	120.00	2				2	
H2320	029	2	1	02	01	H2320_029_2	6	7	17a Eye Exams	10		17a;	2			2			2				2	
H2320	029	2	1	02	01	H2320_029_2	6	8	17b Eyewear	10		17b;	2			2			1	100.00	3		2	
H2320	029	2	1	02	01	H2320_029_2	6	9	8a2 Lab Services	01	8a2;		1	0	40	2			2				2	
H2320	029	3	1	02	01	H2320_029_3	6	1	40% Coinsurance	11	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7h;7i;7k;8a1;8b1;8b2;8b3;9a1;9b;9c;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	13e;14b;	1	40	40	2			2				2	
H2320	029	3	1	02	01	H2320_029_3	6	10	Acupuncture	10		13a;	2			1	20.00	20.00	2				2	
H2320	029	3	1	02	01	H2320_029_3	6	11	7G	01	7g;		1	40	40	1	20.00	20.00	2				2	
H2320	029	3	1	02	01	H2320_029_3	6	12	Embedded Dental 16a and 16b	10		16a;16b;	2			2			2				2	
H2320	029	3	1	02	01	H2320_029_3	6	2	Part B Drugs	01	15;		1	0	20	2			2				2	
H2320	029	3	1	02	01	H2320_029_3	6	3	$0 Copayment	11	6;9d;	9d_2;15;	2			2			2				2	
H2320	029	3	1	02	01	H2320_029_3	6	4	$265 Copayment	11	10a1;10a2;	13d;	2			1	265.00	265.00	2				2	
H2320	029	3	1	02	01	H2320_029_3	6	5	30% Coinsurance	01	11a;11b;		1	30	30	2			2				2	
H2320	029	3	1	02	01	H2320_029_3	6	6	$120 copayment	01	9a2;		2			1	120.00	120.00	2				2	
H2320	029	3	1	02	01	H2320_029_3	6	7	17a Eye Exams	10		17a;	2			2			2				2	
H2320	029	3	1	02	01	H2320_029_3	6	8	17b Eyewear	10		17b;	2			2			1	100.00	3		2	
H2320	029	3	1	02	01	H2320_029_3	6	9	8a2 Lab Services	01	8a2;		1	0	40	2			2				2	
H2320	029	4	1	02	01	H2320_029_4	6	1	40% Coinsurance	11	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7h;7i;7k;8a1;8b1;8b2;8b3;9a1;9b;9c;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	13e;14b;	1	40	40	2			2				2	
H2320	029	4	1	02	01	H2320_029_4	6	10	Acupuncture	10		13a;	2			1	20.00	20.00	2				2	
H2320	029	4	1	02	01	H2320_029_4	6	11	7G	01	7g;		1	40	40	1	20.00	20.00	2				2	
H2320	029	4	1	02	01	H2320_029_4	6	12	Embedded Dental 16a and 16b	10		16a;16b;	2			2			2				2	
H2320	029	4	1	02	01	H2320_029_4	6	2	Part B Drugs	01	15;		1	0	20	2			2				2	
H2320	029	4	1	02	01	H2320_029_4	6	3	$0 Copayment	11	6;9d;	9d_2;15;	2			2			2				2	
H2320	029	4	1	02	01	H2320_029_4	6	4	$265 Copayment	11	10a1;10a2;	13d;	2			1	265.00	265.00	2				2	
H2320	029	4	1	02	01	H2320_029_4	6	5	30% Coinsurance	01	11a;11b;		1	30	30	2			2				2	
H2320	029	4	1	02	01	H2320_029_4	6	6	$120 copayment	01	9a2;		2			1	120.00	120.00	2				2	
H2320	029	4	1	02	01	H2320_029_4	6	7	17a Eye Exams	10		17a;	2			2			2				2	
H2320	029	4	1	02	01	H2320_029_4	6	8	17b Eyewear	10		17b;	2			2			1	100.00	3		2	
H2320	029	4	1	02	01	H2320_029_4	6	9	8a2 Lab Services	01	8a2;		1	0	40	2			2				2	
H2320	029	5	1	02	01	H2320_029_5	6	1	40% Coinsurance	11	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7h;7i;7k;8a1;8b1;8b2;8b3;9a1;9b;9c;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	13e;14b;	1	40	40	2			2				2	
H2320	029	5	1	02	01	H2320_029_5	6	10	Acupuncture	10		13a;	2			1	20.00	20.00	2				2	
H2320	029	5	1	02	01	H2320_029_5	6	11	7G	01	7g;		1	40	40	1	20.00	20.00	2				2	
H2320	029	5	1	02	01	H2320_029_5	6	12	Embedded Dental 16a and 16b	10		16a;16b;	2			2			2				2	
H2320	029	5	1	02	01	H2320_029_5	6	2	Part B Drugs	01	15;		1	0	20	2			2				2	
H2320	029	5	1	02	01	H2320_029_5	6	3	$0 Copayment	11	6;9d;	9d_2;15;	2			2			2				2	
H2320	029	5	1	02	01	H2320_029_5	6	4	$265 Copayment	11	10a1;10a2;	13d;	2			1	265.00	265.00	2				2	
H2320	029	5	1	02	01	H2320_029_5	6	5	30% Coinsurance	01	11a;11b;		1	30	30	2			2				2	
H2320	029	5	1	02	01	H2320_029_5	6	6	$120 copayment	01	9a2;		2			1	120.00	120.00	2				2	
H2320	029	5	1	02	01	H2320_029_5	6	7	17a Eye Exams	10		17a;	2			2			2				2	
H2320	029	5	1	02	01	H2320_029_5	6	8	17b Eyewear	10		17b;	2			2			1	100.00	3		2	
H2320	029	5	1	02	01	H2320_029_5	6	9	8a2 Lab Services	01	8a2;		1	0	40	2			2				2	
H2320	030	1	1	02	01	H2320_030_1	6	1	50% Coinsurance	11	3-1;3-2;3-3;3-4;7a;7b;7c;7d;7e;7f;7h;7i;7k;8a1;8b1;8b2;8b3;9a1;9b;9c;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	13e;14b;	1	50	50	2			2				2	
H2320	030	1	1	02	01	H2320_030_1	6	10	8a2 Lab Services	01	8a2;		1	0	50	2			2				2	
H2320	030	1	1	02	01	H2320_030_1	6	11	Acupuncture	10		13a;	2			1	20.00	20.00	2				2	
H2320	030	1	1	02	01	H2320_030_1	6	12	7G	01	7g;		1	50	50	1	20.00	20.00	2				2	
H2320	030	1	1	02	01	H2320_030_1	6	13	Embedded Dental 16a and 16b	10		16a;16b;	2			2			2				2	
H2320	030	1	1	02	01	H2320_030_1	6	2	30% Coinsurance	01	11a;11b;		1	30	30	2			2				2	
H2320	030	1	1	02	01	H2320_030_1	6	3	Part B Drugs	01	15;		1	0	20	2			2				2	
H2320	030	1	1	02	01	H2320_030_1	6	4	$0 Copayment	11	6;9d;	9d_2;15;	2			2			2				2	
H2320	030	1	1	02	01	H2320_030_1	6	5	$285 Copayment	11	10a1;10a2;	13d;	2			1	285.00	285.00	2				2	
H2320	030	1	1	02	01	H2320_030_1	6	6	40% Coinsurance	01	5;		1	40	40	2			2				2	
H2320	030	1	1	02	01	H2320_030_1	6	7	$120 copayment	01	9a2;		2			1	120.00	120.00	2				2	
H2320	030	1	1	02	01	H2320_030_1	6	8	Embedded Vision 17a	10		17a;	2			2			2				2	
H2320	030	1	1	02	01	H2320_030_1	6	9	17b Eyewear	10		17b;	2			2			1	175.00	3		2	
H2320	030	2	1	02	01	H2320_030_2	6	1	50% Coinsurance	11	3-1;3-2;3-3;3-4;7a;7b;7c;7d;7e;7f;7h;7i;7k;8a1;8b1;8b2;8b3;9a1;9b;9c;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	13e;14b;	1	50	50	2			2				2	
H2320	030	2	1	02	01	H2320_030_2	6	10	8a2 Lab Services	01	8a2;		1	0	50	2			2				2	
H2320	030	2	1	02	01	H2320_030_2	6	11	Acupuncture	10		13a;	2			1	20.00	20.00	2				2	
H2320	030	2	1	02	01	H2320_030_2	6	12	7G	01	7g;		1	50	50	1	20.00	20.00	2				2	
H2320	030	2	1	02	01	H2320_030_2	6	13	Embedded Dental 16a and 16b	10		16a;16b;	2			2			2				2	
H2320	030	2	1	02	01	H2320_030_2	6	2	30% Coinsurance	01	11a;11b;		1	30	30	2			2				2	
H2320	030	2	1	02	01	H2320_030_2	6	3	Part B Drugs	01	15;		1	0	20	2			2				2	
H2320	030	2	1	02	01	H2320_030_2	6	4	$0 Copayment	11	6;9d;	9d_2;15;	2			2			2				2	
H2320	030	2	1	02	01	H2320_030_2	6	5	$285 Copayment	11	10a1;10a2;	13d;	2			1	285.00	285.00	2				2	
H2320	030	2	1	02	01	H2320_030_2	6	6	40% Coinsurance	01	5;		1	40	40	2			2				2	
H2320	030	2	1	02	01	H2320_030_2	6	7	$120 copayment	01	9a2;		2			1	120.00	120.00	2				2	
H2320	030	2	1	02	01	H2320_030_2	6	8	Embedded Vision 17a	10		17a;	2			2			2				2	
H2320	030	2	1	02	01	H2320_030_2	6	9	17b Eyewear	10		17b;	2			2			1	175.00	3		2	
H2320	802	0	1	02	01	H2320_802_0	6	1	20% Coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	7b;13d;13e;14b;14c15;	1	20	20	2			2				2	
H2320	802	0	1	02	01	H2320_802_0	6	2	Part B Drugs	01	15;		1	0	20	2			2				2	
H2320	803	0	1	02	01	H2320_803_0	6	1	20% Coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	7b;13d;13e;14b;14c15;	1	20	20	2			2				2	
H2320	803	0	1	02	01	H2320_803_0	6	2	Part B Drugs	01	15;		1	0	20	2			2				2	
H2320	812	0	1	02	01	H2320_812_0	6	1	20% Coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	7b;13d;13e;14b;14c15;	1	20	20	2			2				2	
H2320	812	0	1	02	01	H2320_812_0	6	2	Part B Drugs	01	15;		1	0	20	2			2				2	
H2320	813	0	1	02	01	H2320_813_0	6	1	20% Coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	7b;13d;13e;14b;14c15;	1	20	20	2			2				2	
H2320	813	0	1	02	01	H2320_813_0	6	2	Part B Drugs	01	15;		1	0	20	2			2				2	
H2354	021	0	1	02	01	H2354_021_0	17	1	POS Covered Services 20%	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	7b;9d_2;14b;14c1;14c2;14c3;	1	20	20	2			2				2	
H2354	021	0	1	02	01	H2354_021_0	17	2	POS Covered Services $0				2			2			2				2	
H2354	802	0	1	02	01	H2354_802_0	12	1	Point of Service Group 1	01	6;14a;		1	0	0	2			2				2	
H2354	802	0	1	02	01	H2354_802_0	12	2	Point of Service Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H2459	001	0	1	02	01	H2459_001_0	10	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7k;8a1;8b1;8b2;8b3;9a1;9a2;9b;9d;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;	1	20	20	2			2				2	
H2459	001	0	1	02	01	H2459_001_0	10	2	Group 2	01	7a;7e;7h;8a2;9c;14a;		2			2			2				2	
H2459	001	0	1	02	01	H2459_001_0	10	3	Group 3	01	10a1;10a2;		2			1	100.00	100.00	2				2	
H2459	001	0	1	02	01	H2459_001_0	10	4	Group 4	01	7c;7d;7f;7i;		2			1	35.00	35.00	2				2	
H2459	001	0	1	02	01	H2459_001_0	10	5	Group 5	01	7g;		2			1	0.00	35.00	2				2	
H2459	001	0	1	02	01	H2459_001_0	10	6	Group 6	10		17b;	2			2			1	150.00	3		2	
H2459	001	0	1	02	01	H2459_001_0	10	7	Group 7	10		16a;16b;	1	0	60	2			1	2000.00	3		2	
H2459	001	0	1	02	01	H2459_001_0	10	8	Group 8	01	15;		1	0	20	1	35.00	35.00	2				2	
H2459	021	1	1	02	01	H2459_021_1	8	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7k;8a1;8b1;8b2;8b3;9a1;9a2;9b;9d;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;	1	20	20	2			2				2	
H2459	021	1	1	02	01	H2459_021_1	8	2	Group 2	11	7a;7e;7h;8a2;9c;14a;	16a;16b;	2			2			2				2	
H2459	021	1	1	02	01	H2459_021_1	8	3	Group 3	01	10a1;10a2;		2			1	225.00	225.00	2				2	
H2459	021	1	1	02	01	H2459_021_1	8	4	Group 4	01	7c;7d;7f;7i;		2			1	20.00	20.00	2				2	
H2459	021	1	1	02	01	H2459_021_1	8	5	Group 5	01	7g;		2			1	0.00	20.00	2				2	
H2459	021	1	1	02	01	H2459_021_1	8	6	Group 6	10		17b;	2			2			1	200.00	3		2	
H2459	021	1	1	02	01	H2459_021_1	8	7	Group 7	01	15;		1	0	20	1	35.00	35.00	2				2	
H2459	021	2	1	02	01	H2459_021_2	8	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7k;8a1;8b1;8b2;8b3;9a1;9a2;9b;9d;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;	1	20	20	2			2				2	
H2459	021	2	1	02	01	H2459_021_2	8	2	Group 2	11	7a;7e;7h;8a2;9c;14a;	16a;16b;	2			2			2				2	
H2459	021	2	1	02	01	H2459_021_2	8	3	Group 3	01	10a1;10a2;		2			1	225.00	225.00	2				2	
H2459	021	2	1	02	01	H2459_021_2	8	4	Group 4	01	7c;7d;7f;7i;		2			1	20.00	20.00	2				2	
H2459	021	2	1	02	01	H2459_021_2	8	5	Group 5	01	7g;		2			1	0.00	20.00	2				2	
H2459	021	2	1	02	01	H2459_021_2	8	6	Group 6	10		17b;	2			2			1	200.00	3		2	
H2459	021	2	1	02	01	H2459_021_2	8	7	Group 7	01	15;		1	0	20	1	35.00	35.00	2				2	
H2459	021	3	1	02	01	H2459_021_3	8	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7k;8a1;8b1;8b2;8b3;9a1;9a2;9b;9d;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;	1	20	20	2			2				2	
H2459	021	3	1	02	01	H2459_021_3	8	2	Group 2	11	7a;7e;7h;8a2;9c;14a;	16a;16b;	2			2			2				2	
H2459	021	3	1	02	01	H2459_021_3	8	3	Group 3	01	10a1;10a2;		2			1	225.00	225.00	2				2	
H2459	021	3	1	02	01	H2459_021_3	8	4	Group 4	01	7c;7d;7f;7i;		2			1	20.00	20.00	2				2	
H2459	021	3	1	02	01	H2459_021_3	8	5	Group 5	01	7g;		2			1	0.00	20.00	2				2	
H2459	021	3	1	02	01	H2459_021_3	8	6	Group 6	10		17b;	2			2			1	200.00	3		2	
H2459	021	3	1	02	01	H2459_021_3	8	7	Group 7	01	15;		1	0	20	1	35.00	35.00	2				2	
H2459	023	1	1	02	01	H2459_023_1	8	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7k;8a1;8b1;8b2;8b3;9a1;9a2;9b;9d;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;	1	20	20	2			2				2	
H2459	023	1	1	02	01	H2459_023_1	8	2	Group 2	01	10a1;10a2;		2			1	250.00	250.00	2				2	
H2459	023	1	1	02	01	H2459_023_1	8	3	Group 3	11	7a;7e;7h;8a2;9c;14a;	16a;16b;	2			2			2				2	
H2459	023	1	1	02	01	H2459_023_1	8	4	Group 4	01	7g;		2			1	0.00	45.00	2				2	
H2459	023	1	1	02	01	H2459_023_1	8	5	Group 5	01	7c;7i;		2			1	40.00	40.00	2				2	
H2459	023	1	1	02	01	H2459_023_1	8	6	Group 6	01	7d;7f;		2			1	45.00	45.00	2				2	
H2459	023	1	1	02	01	H2459_023_1	8	7	Group 7	10		17b;	2			2			1	150.00	3		2	
H2459	023	1	1	02	01	H2459_023_1	8	8	Group 8	01	15;		1	0	20	1	35.00	35.00	2				2	
H2459	023	2	1	02	01	H2459_023_2	8	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7k;8a1;8b1;8b2;8b3;9a1;9a2;9b;9d;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;	1	20	20	2			2				2	
H2459	023	2	1	02	01	H2459_023_2	8	2	Group 2	01	10a1;10a2;		2			1	250.00	250.00	2				2	
H2459	023	2	1	02	01	H2459_023_2	8	3	Group 3	11	7a;7e;7h;8a2;9c;14a;	16a;16b;	2			2			2				2	
H2459	023	2	1	02	01	H2459_023_2	8	4	Group 4	01	7g;		2			1	0.00	45.00	2				2	
H2459	023	2	1	02	01	H2459_023_2	8	5	Group 5	01	7c;7i;		2			1	40.00	40.00	2				2	
H2459	023	2	1	02	01	H2459_023_2	8	6	Group 6	01	7d;7f;		2			1	45.00	45.00	2				2	
H2459	023	2	1	02	01	H2459_023_2	8	7	Group 7	10		17b;	2			2			1	150.00	3		2	
H2459	023	2	1	02	01	H2459_023_2	8	8	Group 8	01	15;		1	0	20	1	35.00	35.00	2				2	
H2459	024	0	1	02	01	H2459_024_0	8	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7k;8a1;8b1;8b2;8b3;9a1;9a2;9b;9d;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;	1	20	20	2			2				2	
H2459	024	0	1	02	01	H2459_024_0	8	2	Group 2	01	10a1;10a2;		2			1	375.00	375.00	2				2	
H2459	024	0	1	02	01	H2459_024_0	8	3	Group 3	11	7a;7e;7h;8a2;9c;14a;	16a;16b;	2			2			2				2	
H2459	024	0	1	02	01	H2459_024_0	8	4	Group 4	01	7c;7d;7f;7i;		2			1	40.00	40.00	2				2	
H2459	024	0	1	02	01	H2459_024_0	8	5	Group 5	01	7g;		2			1	0.00	40.00	2				2	
H2459	024	0	1	02	01	H2459_024_0	8	6	Group 6	10		17b;	2			2			1	100.00	3		2	
H2459	024	0	1	02	01	H2459_024_0	8	7	Group 7	01	15;		1	0	20	1	35.00	35.00	2				2	
H2459	026	1	1	02	01	H2459_026_1	7	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7k;8a1;8b1;8b2;8b3;9a1;9a2;9b;9d;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;	1	20	20	2			2				2	
H2459	026	1	1	02	01	H2459_026_1	7	2	Group 2	01	10a1;10a2;		2			1	275.00	275.00	2				2	
H2459	026	1	1	02	01	H2459_026_1	7	3	Group 3	01	7a;7e;7h;8a2;9c;14a;		2			2			2				2	
H2459	026	1	1	02	01	H2459_026_1	7	4	Group 4	01	7c;7d;7f;7i;		2			1	30.00	30.00	2				2	
H2459	026	1	1	02	01	H2459_026_1	7	5	Group 5	01	7g;		2			1	0.00	30.00	2				2	
H2459	026	1	1	02	01	H2459_026_1	7	6	Group 6	10		16a;16b;	1	0	70	2			1	2000.00	3		2	
H2459	026	1	1	02	01	H2459_026_1	7	7	Group 7	10		17b;	2			2			1	200.00	3		2	
H2459	026	1	1	02	01	H2459_026_1	7	8	Group 8	01	15;		1	0	20	1	35.00	35.00	2				2	
H2459	026	3	1	02	01	H2459_026_3	7	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7k;8a1;8b1;8b2;8b3;9a1;9a2;9b;9d;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;	1	20	20	2			2				2	
H2459	026	3	1	02	01	H2459_026_3	7	2	Group 2	01	10a1;10a2;		2			1	275.00	275.00	2				2	
H2459	026	3	1	02	01	H2459_026_3	7	3	Group 3	01	7a;7e;7h;8a2;9c;14a;		2			2			2				2	
H2459	026	3	1	02	01	H2459_026_3	7	4	Group 4	01	7c;7d;7f;7i;		2			1	30.00	30.00	2				2	
H2459	026	3	1	02	01	H2459_026_3	7	5	Group 5	01	7g;		2			1	0.00	30.00	2				2	
H2459	026	3	1	02	01	H2459_026_3	7	6	Group 6	10		16a;16b;	1	0	70	2			1	2000.00	3		2	
H2459	026	3	1	02	01	H2459_026_3	7	7	Group 7	10		17b;	2			2			1	200.00	3		2	
H2459	026	3	1	02	01	H2459_026_3	7	8	Group 8	01	15;		1	0	20	1	35.00	35.00	2				2	
H2459	026	4	1	02	01	H2459_026_4	7	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7k;8a1;8b1;8b2;8b3;9a1;9a2;9b;9d;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;	1	20	20	2			2				2	
H2459	026	4	1	02	01	H2459_026_4	7	2	Group 2	01	10a1;10a2;		2			1	275.00	275.00	2				2	
H2459	026	4	1	02	01	H2459_026_4	7	3	Group 3	01	7a;7e;7h;8a2;9c;14a;		2			2			2				2	
H2459	026	4	1	02	01	H2459_026_4	7	4	Group 4	01	7c;7d;7f;7i;		2			1	30.00	30.00	2				2	
H2459	026	4	1	02	01	H2459_026_4	7	5	Group 5	01	7g;		2			1	0.00	30.00	2				2	
H2459	026	4	1	02	01	H2459_026_4	7	6	Group 6	10		16a;16b;	1	0	70	2			1	2000.00	3		2	
H2459	026	4	1	02	01	H2459_026_4	7	7	Group 7	10		17b;	2			2			1	200.00	3		2	
H2459	026	4	1	02	01	H2459_026_4	7	8	Group 8	01	15;		1	0	20	1	35.00	35.00	2				2	
H2459	029	0	1	02	01	H2459_029_0	7	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7k;8a1;8b1;8b2;8b3;9a1;9a2;9b;9d;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;	1	20	20	2			2				2	
H2459	029	0	1	02	01	H2459_029_0	7	2	Group 2	01	7a;7e;7h;8a2;9c;14a;		2			2			2				2	
H2459	029	0	1	02	01	H2459_029_0	7	3	Group 3	01	7c;7i;		2			1	40.00	40.00	2				2	
H2459	029	0	1	02	01	H2459_029_0	7	4	Group 4	01	7d;7f;		2			1	45.00	45.00	2				2	
H2459	029	0	1	02	01	H2459_029_0	7	5	Group 5	01	10a1;10a2;		2			1	275.00	275.00	2				2	
H2459	029	0	1	02	01	H2459_029_0	7	6	Group 6	01	7g;		2			1	0.00	45.00	2				2	
H2459	029	0	1	02	01	H2459_029_0	7	7	Group 7	10		17b;	2			2			1	150.00	3		2	
H2459	029	0	1	02	01	H2459_029_0	7	8	Group 8	10		16a;16b;	2			2			1	600.00	3		2	
H2459	029	0	1	02	01	H2459_029_0	7	9	Group 9	01	15;		1	0	20	1	35.00	35.00	2				2	
H2459	030	0	1	02	01	H2459_030_0	10	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7k;8a1;8b1;8b2;8b3;9a1;9a2;9b;9d;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;	1	20	20	2			2				2	
H2459	030	0	1	02	01	H2459_030_0	10	2	Group 2	11	7a;7e;7h;8a2;9c;14a;	16a;16b;	2			2			2				2	
H2459	030	0	1	02	01	H2459_030_0	10	3	Group 3	01	7c;7i;		2			1	40.00	40.00	2				2	
H2459	030	0	1	02	01	H2459_030_0	10	4	Group 4	01	7d;7f;		2			1	45.00	45.00	2				2	
H2459	030	0	1	02	01	H2459_030_0	10	5	Group 5	01	10a1;10a2;		2			1	200.00	200.00	2				2	
H2459	030	0	1	02	01	H2459_030_0	10	6	Group 6	01	7g;		2			1	0.00	45.00	2				2	
H2459	030	0	1	02	01	H2459_030_0	10	7	Group 7	10		17b;	2			2			1	100.00	3		2	
H2459	030	0	1	02	01	H2459_030_0	10	8	Group 8	01	15;		1	0	20	1	35.00	35.00	2				2	
H2459	801	0	1	02	01	H2459_801_0	6	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H2459	801	0	1	02	01	H2459_801_0	6	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H2509	001	0	1	02	01	H2509_001_0	3	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H2509	002	0	1	02	01	H2509_002_0	3	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H2582	002	0	1	02	01	H2582_002_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H2582	004	0	1	02	01	H2582_004_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2582	004	0	1	02	01	H2582_004_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H2582	005	0	1	02	01	H2582_005_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2582	005	0	1	02	01	H2582_005_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H2593	031	0	1	02	01	H2593_031_0	6	1	20% Coinsurance Group	01	3-1;3-2;3-3;3-4;5;7b;7c;7e;7f;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;10a1;10a2;11b;11c;14a;14e2;14e3;14e4;14e5;		1	20	20	2			2				2	
H2593	031	0	1	02	01	H2593_031_0	6	2	$0 Copayment Group	11	6;7a;9d;12;14d;	9d_2;	2			1	0.00	0.00	2				2	
H2593	031	0	1	02	01	H2593_031_0	6	3	SPC $0 - 20%	01	7d;7g;		1	20	20	1	0.00	0.00	2				2	
H2593	031	0	1	02	01	H2593_031_0	6	4	Part B Rx Drugs	01	15;		1	0	20	1	35.00	35.00	2				2	
H2610	807	0	1	02	01	H2610_807_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H2610	807	0	1	02	01	H2610_807_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H2610	808	0	1	02	01	H2610_808_0	2	1	Point of Service Group 1	01	6;14a;		1	0	0	2			2				2	
H2610	808	0	1	02	01	H2610_808_0	2	2	Point of Service Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H2610	809	0	1	02	01	H2610_809_0	2	1	Point of Service Group 1	01	6;14a;		1	0	0	2			2				2	
H2610	809	0	1	02	01	H2610_809_0	2	2	Point of Service Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H2610	810	0	1	02	01	H2610_810_0	2	1	Point of Service Group 1	01	6;14a;		1	0	0	2			2				2	
H2610	810	0	1	02	01	H2610_810_0	2	2	Point of Service Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H2663	006	0	1	02	01	H2663_006_0	9	1	$0 copay	10		14c1;16a;16b;	2			1	0.00	0.00	2				2	
H2663	006	0	1	02	01	H2663_006_0	9	2	$285 copay	01	10a1;10a2;		2			1	285.00	285.00	2				2	
H2663	006	0	1	02	01	H2663_006_0	9	3	0% - 20% coinsurance	01	11c;		1	0	20	2			2				2	
H2663	006	0	1	02	01	H2663_006_0	9	4	0% - 30% coinsurance	01	7g;14a;		1	0	30	2			2				2	
H2663	006	0	1	02	01	H2663_006_0	9	5	30% coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	7f_2;14b;14c2;14c3;14c12;17a;	1	30	30	2			2				2	
H2663	006	0	1	02	01	H2663_006_0	9	6	50% coinsurance	01	12;		1	50	50	2			2				2	
H2663	006	0	1	02	01	H2663_006_0	9	7	OON Wigs	10		14c15;	2			1	0.00	0.00	1	400.00	3		2	
H2663	021	0	1	02	01	H2663_021_0	7	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H2663	022	0	1	02	01	H2663_022_0	4	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H2663	023	0	1	02	01	H2663_023_0	7	1	$0 copay	10		14c1;16a;16b;	2			1	0.00	0.00	2				2	
H2663	023	0	1	02	01	H2663_023_0	7	2	$350 copay	01	10a1;10a2;		2			1	350.00	350.00	2				2	
H2663	023	0	1	02	01	H2663_023_0	7	3	0% - 20% coinsurance	01	11c;		1	0	20	2			2				2	
H2663	023	0	1	02	01	H2663_023_0	7	4	0% - 50% coinsurance	01	7g;14a;		1	0	50	2			2				2	
H2663	023	0	1	02	01	H2663_023_0	7	5	50% coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	9d_2;14b;14c2;14c3;14c12;17a;	1	50	50	2			2				2	
H2663	023	0	1	02	01	H2663_023_0	7	6	OON Wigs	10		14c15;	2			1	0.00	0.00	1	400.00	3		2	
H2663	023	0	1	02	01	H2663_023_0	7	7	Fitness	10		14c4;	2			1	0.00	0.00	1	1200.00	3		2	
H2663	025	0	1	02	01	H2663_025_0	4	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H2663	026	0	1	02	01	H2663_026_0	7	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H2663	028	0	1	02	01	H2663_028_0	7	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H2663	029	0	1	02	01	H2663_029_0	4	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H2663	043	0	1	02	01	H2663_043_0	7	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H2663	061	0	1	02	01	H2663_061_0	7	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H2663	062	0	1	02	01	H2663_062_0	7	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H2663	063	0	1	02	01	H2663_063_0	7	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H2663	063	0	1	02	01	H2663_063_0	7	2	50% coinsurance				1	50	50	2			2				2	
H2722	002	0	1	02	01	H2722_002_0	6	1	50% coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;14b;	1	50	50	2			2				2	
H2722	002	0	1	02	01	H2722_002_0	6	10	Ground Ambulance	01	10a1;		2			1	250.00	250.00	2				2	
H2722	002	0	1	02	01	H2722_002_0	6	2	Non-Medicare Dental	10		16a;16b;	2			2			1	2000.00	3		2	
H2722	002	0	1	02	01	H2722_002_0	6	3	Non-Medicare Eye Exams	10		17a;	1	50	50	2			2				2	
H2722	002	0	1	02	01	H2722_002_0	6	4	Air Ambulance	01	10a2;		2			1	260.00	260.00	2				2	
H2722	002	0	1	02	01	H2722_002_0	6	5	Non-Medicare Hearing Exams	10		18a;	2			2			2				2	
H2722	002	0	1	02	01	H2722_002_0	6	6	ESRD	01	12;		1	20	20	2			2				2	
H2722	002	0	1	02	01	H2722_002_0	6	7	Non-Medicare Eye Wear	10		17b;	2			2			1	400.00	3		2	
H2722	002	0	1	02	01	H2722_002_0	6	8	Hearing Aids	10		18a2;18b;	2			2			1	1100.00	3		2	
H2722	002	0	1	02	01	H2722_002_0	6	9	Part B Rx	01	15;		1	0	50	1	35.00	35.00	2				2	
H2722	003	0	1	02	01	H2722_003_0	8	1	50% coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;14b;	1	50	50	2			2				2	
H2722	003	0	1	02	01	H2722_003_0	8	10	Ground Ambulance	01	10a1;		1	50	50	2			2				2	
H2722	003	0	1	02	01	H2722_003_0	8	2	Non-Medicare Dental	10		16a;16b;	2			2			1	3800.00	3		2	
H2722	003	0	1	02	01	H2722_003_0	8	3	Non-Medicare Eye Exams	10		17a;	1	50	50	2			2				2	
H2722	003	0	1	02	01	H2722_003_0	8	4	Air Ambulance	01	10a2;		1	50	50	2			2				2	
H2722	003	0	1	02	01	H2722_003_0	8	5	Non-Medicare Hearing Exams	10		18a;	2			2			2				2	
H2722	003	0	1	02	01	H2722_003_0	8	6	ESRD	01	12;		1	20	20	2			2				2	
H2722	003	0	1	02	01	H2722_003_0	8	7	Non-Medicare Eye Wear	10		17b;	2			2			1	400.00	3		2	
H2722	003	0	1	02	01	H2722_003_0	8	8	Hearing Aids	10		18a2;18b;	2			2			1	1500.00	3		2	
H2722	003	0	1	02	01	H2722_003_0	8	9	Part B Rx	01	15;		1	0	50	1	35.00	35.00	2				2	
H2722	004	0	1	02	01	H2722_004_0	6	1	50% coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;14b;	1	50	50	2			2				2	
H2722	004	0	1	02	01	H2722_004_0	6	10	Ground Ambulance	01	10a1;		2			1	250.00	250.00	2				2	
H2722	004	0	1	02	01	H2722_004_0	6	2	Non-Medicare Dental	10		16a;16b;	2			2			1	2200.00	3		2	
H2722	004	0	1	02	01	H2722_004_0	6	3	Non-Medicare Eye Exams	10		17a;	1	50	50	2			2				2	
H2722	004	0	1	02	01	H2722_004_0	6	4	Air Ambulance	01	10a2;		2			1	260.00	260.00	2				2	
H2722	004	0	1	02	01	H2722_004_0	6	5	Non-Medicare Hearing Exams	10		18a;	2			2			2				2	
H2722	004	0	1	02	01	H2722_004_0	6	6	ESRD	01	12;		1	20	20	2			2				2	
H2722	004	0	1	02	01	H2722_004_0	6	7	Non-Medicare Eye Wear	10		17b;	2			2			1	300.00	3		2	
H2722	004	0	1	02	01	H2722_004_0	6	8	Hearing Aids	10		18a2;18b;	2			2			1	1100.00	3		2	
H2722	004	0	1	02	01	H2722_004_0	6	9	Part B Rx	01	15;		1	0	50	1	35.00	35.00	2				2	
H2722	005	0	1	02	01	H2722_005_0	6	1	50% coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;14b;	1	50	50	2			2				2	
H2722	005	0	1	02	01	H2722_005_0	6	10	Ground Ambulance	01	10a1;		2			1	250.00	250.00	2				2	
H2722	005	0	1	02	01	H2722_005_0	6	2	Non-Medicare Dental	10		16a;16b;	2			2			1	2000.00	3		2	
H2722	005	0	1	02	01	H2722_005_0	6	3	Non-Medicare Eye Exams	10		17a;	1	50	50	2			2				2	
H2722	005	0	1	02	01	H2722_005_0	6	4	Air Ambulance	01	10a2;		2			1	300.00	300.00	2				2	
H2722	005	0	1	02	01	H2722_005_0	6	5	Non-Medicare Hearing Exams	10		18a;	2			2			2				2	
H2722	005	0	1	02	01	H2722_005_0	6	6	ESRD	01	12;		1	20	20	2			2				2	
H2722	005	0	1	02	01	H2722_005_0	6	7	Non-Medicare Eye Wear	10		17b;	2			2			1	400.00	3		2	
H2722	005	0	1	02	01	H2722_005_0	6	8	Hearing Aids	10		18a2;18b;	2			2			1	1100.00	3		2	
H2722	005	0	1	02	01	H2722_005_0	6	9	Part B Rx	01	15;		1	0	50	1	35.00	35.00	2				2	
H2722	801	0	1	02	01	H2722_801_0	4	1	Part B Rx	01	6;15;		1	0	50	1	35.00	35.00	2				2	
H2722	801	0	1	02	01	H2722_801_0	4	2	Medicare-covered	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	50	50	2			2				2	
H2765	001	0	1	02	01	H2765_001_0	6	1	Ambulance	01	10a1;10a2;		2			1	325.00	325.00	2				2	
H2765	001	0	1	02	01	H2765_001_0	6	2	Dialysis	01	12;		1	20	20	2			2				2	
H2765	001	0	1	02	01	H2765_001_0	6	3	Routine Dental	10		16a;16b;	1	50	50	2			1	1000.00	3		2	
H2765	001	0	1	02	01	H2765_001_0	6	4	Extra Care Benefits	10		7b;13a;14c17;	1	50	50	2			2				2	
H2765	001	0	1	02	01	H2765_001_0	6	5	All Other Services	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	9d_2;14b;	1	30	30	2			2				2	
H2765	001	0	1	02	01	H2765_001_0	6	6	Routine Vision	10		17a;17b;	1	0	50	2			2				2	
H2765	002	0	1	02	01	H2765_002_0	8	1	Ambulance	01	10a1;10a2;		2			1	325.00	325.00	2				2	
H2765	002	0	1	02	01	H2765_002_0	8	2	Dialysis	01	12;		1	20	20	2			2				2	
H2765	002	0	1	02	01	H2765_002_0	8	3	Routine Dental	10		16a;16b;	1	50	50	2			2				2	
H2765	002	0	1	02	01	H2765_002_0	8	4	Routine Vision	10		17a;17b;	1	0	50	2			2				2	
H2765	002	0	1	02	01	H2765_002_0	8	5	All Other Services	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	9d_2;14b;	1	50	50	2			2				2	
H2765	002	0	1	02	01	H2765_002_0	8	6	Extra Care	10		7b;13a;14c17;	1	50	50	2			2				2	
H2765	003	0	1	02	01	H2765_003_0	8	1	Ambulance	01	10a1;10a2;		2			1	300.00	300.00	2				2	
H2765	003	0	1	02	01	H2765_003_0	8	2	Dialysis	01	12;		1	20	20	2			2				2	
H2765	003	0	1	02	01	H2765_003_0	8	3	Routine Vision	10		17a;17b;	1	0	50	2			1	100.00	2		2	
H2765	003	0	1	02	01	H2765_003_0	8	4	Routine Dental	10		16a;16b;	1	50	50	2			1	1250.00	3		2	
H2765	003	0	1	02	01	H2765_003_0	8	5	Extra Care Benefits	10		7b;13a;14c17;	1	50	50	2			2				2	
H2765	003	0	1	02	01	H2765_003_0	8	6	All Other Services	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	9d_2;14b;	1	50	50	2			2				2	
H2765	004	0	1	02	01	H2765_004_0	7	1	Ambulance	01	10a1;10a2;		2			1	275.00	275.00	2				2	
H2765	004	0	1	02	01	H2765_004_0	7	2	Dialysis	01	12;		1	20	20	2			2				2	
H2765	004	0	1	02	01	H2765_004_0	7	3	Routine Dental	10		16a;16b;	1	50	50	2			1	1500.00	3		2	
H2765	004	0	1	02	01	H2765_004_0	7	4	Routine Vision	10		17a;17b;	1	0	50	2			1	100.00	2		2	
H2765	004	0	1	02	01	H2765_004_0	7	5	Extra Care Benefits	10		7b;13a;14c17;	1	50	50	2			1	500.00	3		2	
H2765	004	0	1	02	01	H2765_004_0	7	6	All Other Services	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	9d_2;14b;	1	30	30	2			2				2	
H2802	001	0	1	02	01	H2802_001_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	001	0	1	02	01	H2802_001_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	007	0	1	02	01	H2802_007_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	007	0	1	02	01	H2802_007_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	008	0	1	02	01	H2802_008_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	008	0	1	02	01	H2802_008_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	010	0	1	02	01	H2802_010_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	010	0	1	02	01	H2802_010_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	012	0	1	02	01	H2802_012_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	012	0	1	02	01	H2802_012_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	016	0	1	02	01	H2802_016_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	016	0	1	02	01	H2802_016_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	018	0	1	02	01	H2802_018_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	018	0	1	02	01	H2802_018_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	024	0	1	02	01	H2802_024_0	5	1	Group 1	10		16b;	1	0	50	2			2				2	
H2802	024	0	1	02	01	H2802_024_0	5	2	Group 2	10		16a;	2			1	0.00	0.00	2				2	
H2802	025	0	1	02	01	H2802_025_0	6	1	Group 1	10		16b;	1	0	50	2			2				2	
H2802	025	0	1	02	01	H2802_025_0	6	2	Group 2	10		16a;	2			1	0.00	0.00	2				2	
H2802	027	0	1	02	01	H2802_027_0	4	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;18a;	7f_2;9d_2;14b;17a;18a;	1	30	30	2			2				2	
H2802	027	0	1	02	01	H2802_027_0	4	2	Group 2	01	10a1;10a2;12;		1	20	20	2			2				2	
H2802	027	0	1	02	01	H2802_027_0	4	3	Group 3	11	7k;8a2;17b;	16a;16b;17b;18b;	2			1	0.00	0.00	2				2	
H2802	027	0	1	02	01	H2802_027_0	4	4	Group 4	01	14a;15;		1	0	30	2			2				2	
H2802	027	0	1	02	01	H2802_027_0	4	5	Group 5	10		13b;14c8;	2			1	0.00	0.00	1	125.00	5		2	
H2802	027	0	1	02	01	H2802_027_0	4	6	Group 6	10		10b1;	1	75	75	2			2				2	
H2802	028	0	1	02	01	H2802_028_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	028	0	1	02	01	H2802_028_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	029	0	1	02	01	H2802_029_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	029	0	1	02	01	H2802_029_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	030	0	1	02	01	H2802_030_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	030	0	1	02	01	H2802_030_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	031	0	1	02	01	H2802_031_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	031	0	1	02	01	H2802_031_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	032	0	1	02	01	H2802_032_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	032	0	1	02	01	H2802_032_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	033	0	1	02	01	H2802_033_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	033	0	1	02	01	H2802_033_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	034	0	1	02	01	H2802_034_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	034	0	1	02	01	H2802_034_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	035	0	1	02	01	H2802_035_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	035	0	1	02	01	H2802_035_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	041	0	1	02	01	H2802_041_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	041	0	1	02	01	H2802_041_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	044	0	1	02	01	H2802_044_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	044	0	1	02	01	H2802_044_0	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	048	0	1	02	01	H2802_048_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	048	0	1	02	01	H2802_048_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	049	0	1	02	01	H2802_049_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	049	0	1	02	01	H2802_049_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	050	0	1	02	01	H2802_050_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	050	0	1	02	01	H2802_050_0	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	052	0	1	02	01	H2802_052_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	052	0	1	02	01	H2802_052_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	053	0	1	02	01	H2802_053_0	3	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H2802	054	0	1	02	01	H2802_054_0	6	1	Group 1	10		16b;	1	0	50	2			2				2	
H2802	054	0	1	02	01	H2802_054_0	6	2	Group 2	10		16a;	2			1	0.00	0.00	2				2	
H2802	055	0	1	02	01	H2802_055_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	055	0	1	02	01	H2802_055_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	056	0	1	02	01	H2802_056_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	056	0	1	02	01	H2802_056_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	057	0	1	02	01	H2802_057_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	057	0	1	02	01	H2802_057_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	058	0	1	02	01	H2802_058_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	058	0	1	02	01	H2802_058_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	059	0	1	02	01	H2802_059_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	060	0	1	02	01	H2802_060_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	060	0	1	02	01	H2802_060_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	061	0	1	02	01	H2802_061_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	061	0	1	02	01	H2802_061_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	062	0	1	02	01	H2802_062_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H2802	062	0	1	02	01	H2802_062_0	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H2802	063	0	1	02	01	H2802_063_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3113	008	0	1	02	01	H3113_008_0	5	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H3113	009	0	1	02	01	H3113_009_0	3	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H3113	010	0	1	02	01	H3113_010_0	3	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H3113	011	0	1	02	01	H3113_011_0	3	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H3113	013	0	1	02	01	H3113_013_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H3113	014	0	1	02	01	H3113_014_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3113	014	0	1	02	01	H3113_014_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H3146	001	0	1	02	01	H3146_001_0	8	1	20% Coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3146	004	0	1	02	01	H3146_004_0	8	1	20% Coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3146	007	0	1	02	01	H3146_007_0	8	1	20% Coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3146	014	0	1	02	01	H3146_014_0	8	1	$0 copay				2			1	0.00	0.00	2				2	
H3146	014	0	1	02	01	H3146_014_0	8	2	20% Coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3146	020	0	1	02	01	H3146_020_0	9	1	20% Coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3152	022	0	1	02	01	H3152_022_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3152	048	0	1	02	01	H3152_048_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3152	080	0	1	02	01	H3152_080_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3192	001	0	1	02	01	H3192_001_0	8	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3192	001	0	1	02	01	H3192_001_0	8	2	$450 copay				2			1	450.00	450.00	2				2	
H3192	001	0	1	02	01	H3192_001_0	8	3	30% coinsurance				1	30	30	2			2				2	
H3192	002	0	1	02	01	H3192_002_0	9	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3192	003	0	1	02	01	H3192_003_0	8	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3192	004	0	1	02	01	H3192_004_0	8	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3192	005	0	1	02	01	H3192_005_0	8	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3192	006	0	1	02	01	H3192_006_0	8	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3192	010	0	1	02	01	H3192_010_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3192	011	0	1	02	01	H3192_011_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3192	012	0	1	02	01	H3192_012_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3192	013	0	1	02	01	H3192_013_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3192	017	0	1	02	01	H3192_017_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3192	020	0	1	02	01	H3192_020_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3204	015	0	1	02	01	H3204_015_0	8	1	Zero Cost Share	11	6;9d;11c;14d;14e1;14e2;14e3;14e4;14e5;	9d_2;	2			2			2				2	
H3204	015	0	1	02	01	H3204_015_0	8	10	$45.00	10		13a;	2			1	45.00	45.00	2				2	
H3204	015	0	1	02	01	H3204_015_0	8	11	$35.00	01	7a;		2			1	35.00	35.00	2				2	
H3204	015	0	1	02	01	H3204_015_0	8	12	$120.00	01	9a2;		2			1	120.00	120.00	2				2	
H3204	015	0	1	02	01	H3204_015_0	8	2	$40.00	11	3-1;3-2;3-3;3-4;7c;7g;7i;14a;	14b;14c1;14c2;14c3;14c4;14c5;14c6;14c7;14c9;14c12;	2			1	40.00	40.00	2				2	
H3204	015	0	1	02	01	H3204_015_0	8	3	$60				2			1	60.00	60.00	2				2	
H3204	015	0	1	02	01	H3204_015_0	8	4	Diag/Therapeutic Radiological Services	01	8b1;8b2;		1	20	20	1	350.00	350.00	2				2	
H3204	015	0	1	02	01	H3204_015_0	8	5	20%	01	12;15;		1	20	20	2			2				2	
H3204	015	0	1	02	01	H3204_015_0	8	6	25%	01	11a;11b;17b;		1	25	25	2			2				2	
H3204	015	0	1	02	01	H3204_015_0	8	7	$525.00	01	9a1;9b;		2			1	525.00	525.00	2				2	
H3204	015	0	1	02	01	H3204_015_0	8	8	$135.00				2			1	135.00	135.00	2				2	
H3204	015	0	1	02	01	H3204_015_0	8	9	$65.00	11	5;7b;7d;7e;7f;7h;7k;8a1;8a2;8b3;9c;16b;17a;18a;	7b;17a;18a;	2			1	65.00	65.00	2				2	
H3204	808	0	1	02	01	H3204_808_0	1	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H3204	808	0	1	02	01	H3204_808_0	1	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3204	809	0	1	02	01	H3204_809_0	1	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H3204	809	0	1	02	01	H3204_809_0	1	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3204	810	0	1	02	01	H3204_810_0	1	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H3204	810	0	1	02	01	H3204_810_0	1	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3240	017	0	1	02	01	H3240_017_0	6	1	20%	01	3-1;3-2;3-3;3-4;5;7b;7c;7e;7f;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;10a1;10a2;11b;11c;14a;14e2;14e3;14e4;14e5;		1	20	20	2			2				2	
H3240	017	0	1	02	01	H3240_017_0	6	2	$0 or 20% 7d 7g	01	7d;7g;		1	20	20	1	0.00	0.00	2				2	
H3240	017	0	1	02	01	H3240_017_0	6	3	$0	11	6;7a;9d;12;14d;	9d_2;	2			1	0.00	0.00	2				2	
H3240	017	0	1	02	01	H3240_017_0	6	4	Part B Rx Drugs	01	15;		1	0	20	1	35.00	35.00	2				2	
H3240	024	0	1	02	01	H3240_024_0	7	1	20%	11	3-1;3-2;3-3;3-4;5;6;7b;7c;7i;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9d;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17b;	9d_2;	1	20	20	2			2				2	
H3240	024	0	1	02	01	H3240_024_0	7	2	$0	01	7a;7d;7f;10a1;10a2;18a;		2			1	0.00	0.00	2				2	
H3240	024	0	1	02	01	H3240_024_0	7	3	7G & 17A	01	7g;17a;		1	20	20	1	0.00	0.00	2				2	
H3240	024	0	1	02	01	H3240_024_0	7	4	Part B Rx Drugs	01	15;		1	0	20	1	35.00	35.00	2				2	
H3276	001	0	1	02	01	H3276_001_0	12	1	Dental	10		16a;16b;	2			2			1	3000.00	3		2	
H3276	003	0	1	02	01	H3276_003_0	11	1	Dental	10		16a;16b;	2			2			1	2000.00	3		2	
H3305	007	0	1	02	01	H3305_007_0	8	1	30%	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9d;11a;11b;14a;16b;17a;18a;		1	30	30	2			2				2	
H3305	007	0	1	02	01	H3305_007_0	8	2	Eyewear	01	17b;		1	20	20	2			2				2	
H3305	007	0	1	02	01	H3305_007_0	8	3	Ambulance	01	10a1;10a2;		2			1	75.00	150.00	2				2	
H3305	007	0	1	02	01	H3305_007_0	8	4	Dental	10		16a;16b;	1	20	50	2			1	2000.00	3		2	
H3305	007	0	1	02	01	H3305_007_0	8	5	Non-Medicare Covered Routine Eye Exam	10		17a;	2			2			1	300.00	3		2	
H3305	015	0	1	02	01	H3305_015_0	10	1	30%	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9d;11a;11b;14a;16b;17a;18a;		1	30	30	2			2				2	
H3305	015	0	1	02	01	H3305_015_0	10	2	Eyewear	01	17b;		1	20	20	2			2				2	
H3305	015	0	1	02	01	H3305_015_0	10	3	Ambulance	01	10a1;10a2;		2			1	160.00	300.00	2				2	
H3305	015	0	1	02	01	H3305_015_0	10	4	Non-Medicare Covered Routine Eye Exams	10		17a;	2			2			1	300.00	3		2	
H3305	015	0	1	02	01	H3305_015_0	10	5	Dental	10		16a;16b;	1	20	50	2			1	2000.00	3		2	
H3305	020	0	1	02	01	H3305_020_0	9	1	30%	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9d;11a;11b;14a;16b;17a;18a;		1	30	30	2			2				2	
H3305	020	0	1	02	01	H3305_020_0	9	2	Eyewear	01	17b;		1	20	20	2			2				2	
H3305	020	0	1	02	01	H3305_020_0	9	3	Ambulance	01	10a1;10a2;		2			1	100.00	200.00	2				2	
H3305	020	0	1	02	01	H3305_020_0	9	4	Dental	10		16a;16b;	1	20	50	2			1	2000.00	3		2	
H3305	020	0	1	02	01	H3305_020_0	9	5	Non-Medicare Covered Routine Eye Exam	10		17a;	2			2			1	300.00	3		2	
H3305	021	0	1	02	01	H3305_021_0	10	1	30%	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9d;11a;11b;14a;16b;17a;18a;		1	30	30	2			2				2	
H3305	021	0	1	02	01	H3305_021_0	10	2	Eyewear	01	17b;		1	20	20	2			2				2	
H3305	021	0	1	02	01	H3305_021_0	10	3	Ambulance	01	10a1;10a2;		2			1	100.00	200.00	2				2	
H3305	021	0	1	02	01	H3305_021_0	10	4	Non-Medicare Covered Routine Eye Exam	10		17a;	2			2			1	300.00	3		2	
H3305	021	0	1	02	01	H3305_021_0	10	5	Dental	10		16a;16b;	1	20	50	2			1	2000.00	3		2	
H3305	022	0	1	02	01	H3305_022_0	10	1	30%	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9d;11a;11b;14a;16b;17a;18a;		1	30	30	2			2				2	
H3305	022	0	1	02	01	H3305_022_0	10	2	Eyewear	01	17b;		1	20	20	2			2				2	
H3305	022	0	1	02	01	H3305_022_0	10	3	Ambulance	01	10a1;10a2;		2			1	175.00	300.00	2				2	
H3305	022	0	1	02	01	H3305_022_0	10	4	Non-Medicare Covered Routine Eye Exam	10		17a;	2			2			1	300.00	3		2	
H3305	022	0	1	02	01	H3305_022_0	10	5	Dental	10		16a;16b;	1	20	50	2			1	2000.00	3		2	
H3305	030	0	1	02	01	H3305_030_0	10	1	30%	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9d;11a;11b;14a;16b;17a;18a;		1	30	30	2			2				2	
H3305	030	0	1	02	01	H3305_030_0	10	2	Eyewear	01	17b;		1	20	20	2			2				2	
H3305	030	0	1	02	01	H3305_030_0	10	3	Ambulance	01	10a1;10a2;		2			1	250.00	500.00	2				2	
H3305	030	0	1	02	01	H3305_030_0	10	4	Non-Medicare Covered Routine Eye Exam	10		17a;	2			2			1	300.00	3		2	
H3305	030	0	1	02	01	H3305_030_0	10	5	Dental	10		16a;16b;	1	20	50	2			1	1500.00	3		2	
H3305	032	0	1	02	01	H3305_032_0	10	1	30%	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9d;11a;11b;14a;16b;17a;18a;		1	30	30	2			2				2	
H3305	032	0	1	02	01	H3305_032_0	10	2	Eyewear	01	17b;		1	20	20	2			2				2	
H3305	032	0	1	02	01	H3305_032_0	10	3	Ambulance	01	10a1;10a2;		2			1	250.00	350.00	2				2	
H3305	032	0	1	02	01	H3305_032_0	10	4	Non-Medicare Covered Routine Eye Exam	10		17a;	2			2			1	300.00	3		2	
H3305	032	0	1	02	01	H3305_032_0	10	5	Dental	10		16a;16b;	1	20	50	2			1	1250.00	3		2	
H3305	801	0	1	02	01	H3305_801_0	4	1	Point of Service Group 1	01	6;14a;		1	0	0	2			2				2	
H3305	801	0	1	02	01	H3305_801_0	4	2	Point of Service Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3305	803	0	1	02	01	H3305_803_0	4	1	Point of Service Group 1	01	6;14a;		1	0	0	2			2				2	
H3305	803	0	1	02	01	H3305_803_0	4	2	Point of Service Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3305	804	0	1	02	01	H3305_804_0	4	1	Point of Service Group 1	01	6;14a;		1	0	0	2			2				2	
H3305	804	0	1	02	01	H3305_804_0	4	2	Point of Service Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3307	002	0	1	02	01	H3307_002_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3307	002	0	1	02	01	H3307_002_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H3307	012	0	1	02	01	H3307_012_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3307	012	0	1	02	01	H3307_012_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H3307	015	0	1	02	01	H3307_015_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3307	018	0	1	02	01	H3307_018_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3307	023	0	1	02	01	H3307_023_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3312	062	0	1	02	01	H3312_062_0	8	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H3312	065	0	1	02	01	H3312_065_0	7	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H3330	820	0	1	02	01	H3330_820_0	5	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H3330	820	0	1	02	01	H3330_820_0	5	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3330	821	0	1	02	01	H3330_821_0	5	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H3330	821	0	1	02	01	H3330_821_0	5	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3347	002	0	1	02	01	H3347_002_0	10	1	MCB_ 0%-20%Coinsurance-7g	01	7g;		1	0	20	2			2				2	
H3347	002	0	1	02	01	H3347_002_0	10	2	Non_MCB $0 Copay	10		7f_2;	2			1	0.00	0.00	2				2	
H3347	002	0	1	02	01	H3347_002_0	10	3	Non_MCB $0 Copay Prev-Dental	10		16a;	2			1	0.00	0.00	2				2	
H3347	002	0	1	02	01	H3347_002_0	10	4	Non_MCB $0 Copay Comprehensive Dental	10		16b;	2			1	0.00	0.00	1	1500.00	3		2	
H3347	002	0	1	02	01	H3347_002_0	10	5	MCB_20% Coinsurance	01	7c;7d;7e;7f;7h;7i;		1	20	20	2			2				2	
H3347	003	0	1	02	01	H3347_003_0	11	1	MCB_20% Coinsurance	01	7b;7e;7h;8a1;8b1;8b2;8b3;9a1;9a2;9b;14e1;14e2;17a;		1	20	20	2			2				2	
H3347	003	0	1	02	01	H3347_003_0	11	2	MCB_$0 Copay	01	6;7a;7f;8a2;14a;14e3;14e4;14e5;		2			1	0.00	0.00	2				2	
H3347	003	0	1	02	01	H3347_003_0	11	3	MCB_%0-20% Coinsurance_7g	01	7g;		1	0	20	2			2				2	
H3347	003	0	1	02	01	H3347_003_0	11	4	Non-MCB $0 Copay_13a_14c17	10		13a;14c17;	2			1	0.00	0.00	2				2	
H3347	003	0	1	02	01	H3347_003_0	11	5	MCB_%0-20% Coinsurance_7d	01	7d;		1	0	20	2			2				2	
H3347	007	0	1	02	01	H3347_007_0	10	1	MCB_$0-20% Coinsurance_7g	01	7g;		1	0	20	2			2				2	
H3347	007	0	1	02	01	H3347_007_0	10	2	NON_MCB $0 Copay_7f	10		7f_2;	2			1	0.00	0.00	2				2	
H3347	007	0	1	02	01	H3347_007_0	10	3	Non_MCB $0 Copay Prev-Dental_16a	10		16a;	2			1	0.00	0.00	2				2	
H3347	007	0	1	02	01	H3347_007_0	10	4	Non_MCB  $0 Copay Comprehensive Dental	10		16b;	2			1	0.00	0.00	2				2	
H3347	007	0	1	02	01	H3347_007_0	10	5	MCB_20% Coinsurance	01	7c;7d;7f;7i;		1	20	20	2			2				2	
H3347	009	0	1	02	01	H3347_009_0	10	1	MCB_ $0-$25 Copay Physician Spec Serv 7d	01	7d;		2			1	0.00	25.00	2				2	
H3347	009	0	1	02	01	H3347_009_0	10	2	MCB_$5-$20 Copay Mental Health 7E	01	7e;		2			1	5.00	20.00	2				2	
H3347	009	0	1	02	01	H3347_009_0	10	3	MCB_$25 Copay 7c_7i	01	7c;7i;		2			1	25.00	25.00	2				2	
H3347	009	0	1	02	01	H3347_009_0	10	4	NON_MCB_$25 Copay Podiatry Serv 7f	10		7f_2;	2			1	25.00	25.00	2				2	
H3347	009	0	1	02	01	H3347_009_0	10	5	Non_MCB $0 copay Preventive Dental	10		16a;	2			2			2				2	
H3347	009	0	1	02	01	H3347_009_0	10	6	Non_MCB $0-$150 Comprehensive Dental	10		16b;	2			1	0.00	150.00	2				2	
H3347	009	0	1	02	01	H3347_009_0	10	7	MCB- $5-$25 Copay Psychiatric Serv_7H	01	7h;		2			1	5.00	25.00	2				2	
H3347	009	0	1	02	01	H3347_009_0	10	8	MCB_$0-$25 Copay 7g. Other Health Care	01	7g;		2			1	0.00	25.00	2				2	
H3347	009	0	1	02	01	H3347_009_0	10	9	MCB_$25 Copay Podiatry Serv 7f	01	7f;		2			1	25.00	25.00	2				2	
H3347	015	0	1	02	01	H3347_015_0	9	1	MCB_$0 Copay	01	6;7a;8b1;14a;14e3;14e4;14e5;		2			1	0.00	0.00	2				2	
H3347	015	0	1	02	01	H3347_015_0	9	2	MCB_20% Coinsurance	01	7b;7c;7d;7e;7f;7h;7i;8a1;8b2;8b3;9a1;9a2;9b;14e1;14e2;17a;		1	20	20	2			2				2	
H3347	015	0	1	02	01	H3347_015_0	9	3	Non_MCB $0 Copay_13a_14c17	10		13a;14c17;	2			1	0.00	0.00	2				2	
H3347	015	0	1	02	01	H3347_015_0	9	4	MCB_0%-20% Coinsurance_7g	01	7g;		1	0	20	2			2				2	
H3347	015	0	1	02	01	H3347_015_0	9	5	MCB-$10 Copay Lab Services (8a2)	01	8a2;		2			1	10.00	10.00	2				2	
H3347	016	0	1	02	01	H3347_016_0	10	1	MCB_$35 Copay	01	7c;7f;7i;		2			1	35.00	35.00	2				2	
H3347	016	0	1	02	01	H3347_016_0	10	2	MCB_ $0-$35 Copay Physician Spec Serv 7d	01	7d;		2			1	0.00	35.00	2				2	
H3347	016	0	1	02	01	H3347_016_0	10	3	MCB_$5-$20 Copay Mental Health 7e	01	7e;		2			1	5.00	20.00	2				2	
H3347	016	0	1	02	01	H3347_016_0	10	4	Non_MCB $35 Copay Podiatry Serv 7f	10		7f_2;	2			1	35.00	35.00	2				2	
H3347	016	0	1	02	01	H3347_016_0	10	5	MCB- $5-$25 Copay Psychiatric Serv_7H	01	7h;		2			1	5.00	25.00	2				2	
H3347	016	0	1	02	01	H3347_016_0	10	6	Non_MCB $0 copay Preventive Dental	10		16a;	2			1	0.00	0.00	2				2	
H3347	016	0	1	02	01	H3347_016_0	10	7	Non_MCB $0 Comprehensive Dental	10		16b;	2			1	0.00	0.00	1	1500.00	3		2	
H3347	016	0	1	02	01	H3347_016_0	10	8	MCB-$0-$35 Other Health Care 7g	01	7g;		2			1	0.00	35.00	2				2	
H3347	018	0	1	02	01	H3347_018_0	9	1	Non-MCB $0 Copay_13a_14c17_7b1	10		7b;13a;14c17;	2			1	0.00	0.00	2				2	
H3347	018	0	1	02	01	H3347_018_0	9	10	MCB_ $185 Copay_9a1	01	9a1;		2			1	185.00	185.00	2				2	
H3347	018	0	1	02	01	H3347_018_0	9	11	MCB_$200 Copay_9a2	01	9a2;		2			1	200.00	200.00	2				2	
H3347	018	0	1	02	01	H3347_018_0	9	12	NON-MCB_$10 Copay_7f	10		7f_2;	2			1	10.00	10.00	2				2	
H3347	018	0	1	02	01	H3347_018_0	9	13	MCB_$10 copay_7f	01	7f;		2			1	10.00	10.00	2				2	
H3347	018	0	1	02	01	H3347_018_0	9	2	MCB_$100 Copay_9b	01	9b;		2			1	100.00	100.00	2				2	
H3347	018	0	1	02	01	H3347_018_0	9	3	MCB_$0 Copay	01	6;7a;7b;8a1;8a2;8b3;14a;14e1;14e2;14e3;14e4;14e5;17a;		2			1	0.00	0.00	2				2	
H3347	018	0	1	02	01	H3347_018_0	9	4	MCB_$45 Copay_7d	01	7d;		2			1	45.00	45.00	2				2	
H3347	018	0	1	02	01	H3347_018_0	9	5	MCB_ $0 Copay_7g	01	7g;		2			1	0.00	0.00	2				2	
H3347	018	0	1	02	01	H3347_018_0	9	6	MCB_ $45 Copay_7e	01	7e;		2			1	45.00	45.00	2				2	
H3347	018	0	1	02	01	H3347_018_0	9	7	MCB_ $40 Copay_7c_7i	01	7c;7i;		2			1	40.00	40.00	2				2	
H3347	018	0	1	02	01	H3347_018_0	9	8	MCB_$45 Copay _7h	01	7h;		2			1	45.00	45.00	2				2	
H3347	018	0	1	02	01	H3347_018_0	9	9	MCB_$75 Copay_8b1_8b2	01	8b1;8b2;		2			1	75.00	75.00	2				2	
H3351	001	0	1	02	01	H3351_001_0	5	1	POS Group #1	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	30	30	2			2				2	
H3351	001	0	1	02	01	H3351_001_0	5	2	POS Group #2	01	12;		1	20	20	2			2				2	
H3351	001	0	1	02	01	H3351_001_0	5	3	Ambulance	01	10a1;10a2;		2			1	150.00	150.00	2				2	
H3351	002	0	1	02	01	H3351_002_0	6	1	POS Group #1	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	30	30	2			2				2	
H3351	002	0	1	02	01	H3351_002_0	6	2	POS Group #2	01	12;		1	20	20	2			2				2	
H3351	002	0	1	02	01	H3351_002_0	6	3	Ambulance	01	10a1;10a2;		2			1	100.00	100.00	2				2	
H3351	006	0	1	02	01	H3351_006_0	6	1	POS Group #1	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	30	30	2			2				2	
H3351	006	0	1	02	01	H3351_006_0	6	2	POS Group #2	01	12;		1	20	20	2			2				2	
H3351	006	0	1	02	01	H3351_006_0	6	3	Ambulance	01	10a1;10a2;		2			1	150.00	150.00	2				2	
H3351	007	0	1	02	01	H3351_007_0	5	1	POS Group #1	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	30	30	2			2				2	
H3351	007	0	1	02	01	H3351_007_0	5	2	POS Group #2	01	12;		1	20	20	2			2				2	
H3351	007	0	1	02	01	H3351_007_0	5	3	Ambulance	01	10a1;10a2;		2			1	150.00	150.00	2				2	
H3351	012	0	1	02	01	H3351_012_0	6	1	POS Group #1	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	30	30	2			2				2	
H3351	012	0	1	02	01	H3351_012_0	6	2	POS Group #2	01	12;		1	20	20	2			2				2	
H3351	012	0	1	02	01	H3351_012_0	6	3	Ambulance	01	10a1;10a2;		2			1	200.00	200.00	2				2	
H3351	013	0	1	02	01	H3351_013_0	6	1	POS Group #1	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	30	30	2			2				2	
H3351	013	0	1	02	01	H3351_013_0	6	2	POS Group #2	01	12;		1	20	20	2			2				2	
H3351	013	0	1	02	01	H3351_013_0	6	3	Ambulance	01	10a1;10a2;		2			1	200.00	200.00	2				2	
H3351	018	0	1	02	01	H3351_018_0	6	1	POS Group #1	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	30	30	2			2				2	
H3351	018	0	1	02	01	H3351_018_0	6	2	POS Group #2	01	12;		1	20	20	2			2				2	
H3351	018	0	1	02	01	H3351_018_0	6	3	Ambulance	01	10a1;10a2;		2			1	225.00	225.00	2				2	
H3351	019	0	1	02	01	H3351_019_0	6	1	POS Group #1	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	30	30	2			2				2	
H3351	019	0	1	02	01	H3351_019_0	6	2	POS Group #2	01	12;		1	20	20	2			2				2	
H3351	019	0	1	02	01	H3351_019_0	6	3	Ambulance	01	10a1;10a2;		2			1	275.00	275.00	2				2	
H3351	801	0	1	02	01	H3351_801_0	4	1	Point of Service Group 1	01	6;14a;		1	0	0	2			2				2	
H3351	801	0	1	02	01	H3351_801_0	4	2	Point of Service Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3351	802	0	1	02	01	H3351_802_0	4	1	Point of Service Group 1	01	6;14a;		1	0	0	2			2				2	
H3351	802	0	1	02	01	H3351_802_0	4	2	Point of Service Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3351	803	0	1	02	01	H3351_803_0	4	1	Point of Service Group 1	01	6;14a;		1	0	0	2			2				2	
H3351	803	0	1	02	01	H3351_803_0	4	2	Point of Service Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3351	804	0	1	02	01	H3351_804_0	4	1	Point of Service Group 1	01	6;14a;		1	0	0	2			2				2	
H3351	804	0	1	02	01	H3351_804_0	4	2	Point of Service Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3351	805	0	1	02	01	H3351_805_0	4	1	Point of Service Group 1	01	6;14a;		1	0	0	2			2				2	
H3351	805	0	1	02	01	H3351_805_0	4	2	Point of Service Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3351	806	0	1	02	01	H3351_806_0	4	1	Point of Service Group 1	01	6;14a;		1	0	0	2			2				2	
H3351	806	0	1	02	01	H3351_806_0	4	2	Point of Service Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3362	807	0	1	02	01	H3362_807_0	3	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H3362	807	0	1	02	01	H3362_807_0	3	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3362	819	0	1	02	01	H3362_819_0	3	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H3362	819	0	1	02	01	H3362_819_0	3	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3362	822	0	1	02	01	H3362_822_0	3	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H3362	822	0	1	02	01	H3362_822_0	3	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3379	001	0	1	02	01	H3379_001_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3379	022	0	1	02	01	H3379_022_0	5	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H3379	039	0	1	02	01	H3379_039_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3379	039	0	1	02	01	H3379_039_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H3379	040	0	1	02	01	H3379_040_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3379	040	0	1	02	01	H3379_040_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H3379	041	0	1	02	01	H3379_041_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3379	041	0	1	02	01	H3379_041_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H3379	043	0	1	02	01	H3379_043_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3379	045	0	1	02	01	H3379_045_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3379	045	0	1	02	01	H3379_045_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H3379	046	0	1	02	01	H3379_046_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3379	050	0	1	02	01	H3379_050_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3379	051	0	1	02	01	H3379_051_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3379	051	0	1	02	01	H3379_051_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H3384	811	0	1	02	01	H3384_811_0	5	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H3384	811	0	1	02	01	H3384_811_0	5	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3384	812	0	1	02	01	H3384_812_0	5	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H3384	812	0	1	02	01	H3384_812_0	5	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3387	014	1	1	02	01	H3387_014_1	3	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H3387	014	2	1	02	01	H3387_014_2	3	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H3387	015	1	1	02	01	H3387_015_1	3	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H3387	015	2	1	02	01	H3387_015_2	3	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H3449	012	0	1	02	01	H3449_012_0	7	1	POS Blue Dental	10		16a;16b;	1	20	20	2			1	2000.00	3		2	
H3449	023	1	1	02	01	H3449_023_1	10	1	POS Blue Dental	10		16a;16b;	1	20	20	2			1	2000.00	3		2	
H3449	023	2	1	02	01	H3449_023_2	10	1	POS Blue Dental	10		16a;16b;	1	20	20	2			1	2000.00	3		2	
H3449	023	4	1	02	01	H3449_023_4	10	1	POS Blue Dental	10		16a;16b;	1	20	20	2			1	2000.00	3		2	
H3449	023	5	1	02	01	H3449_023_5	10	1	POS Blue Dental	10		16a;16b;	1	20	20	2			1	2000.00	3		2	
H3449	024	1	1	02	01	H3449_024_1	10	1	POS Blue Dental	10		16a;16b;	1	20	20	2			1	2000.00	3		2	
H3449	024	2	1	02	01	H3449_024_2	10	1	POS Blue Dental	10		16a;16b;	1	20	20	2			1	2000.00	3		2	
H3449	024	3	1	02	01	H3449_024_3	10	1	POS Blue Dental	10		16a;16b;	1	20	20	2			1	2000.00	3		2	
H3467	001	0	1	02	01	H3467_001_0	5	1	20% Coinsurance	01	7d;		1	20	20	2			2				2	
H3471	018	0	1	02	01	H3471_018_0	6	1	POS Group = $0	11	9d;14a;14d;14e1;14e2;14e3;14e4;14e5;	14c7;	2			2			2				2	
H3471	018	0	1	02	01	H3471_018_0	6	2	POS Group = 30%	11	3-1;3-2;3-3;3-4;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;11a;11b;11c;15;17a;17b;18a;	14b;	1	30	30	2			2				2	
H3471	018	0	1	02	01	H3471_018_0	6	3	POS Group = 50%	01	12;		1	50	50	2			2				2	
H3471	018	0	1	02	01	H3471_018_0	6	4	POS Group = $65	01	5;		2			1	65.00	65.00	2				2	
H3471	018	0	1	02	01	H3471_018_0	6	5	POS Group = $250	10		16a;16b;	2			2			1	250.00	3		2	
H3471	018	0	1	02	01	H3471_018_0	6	6	POS Group = $50	01	16b;		2			1	50.00	50.00	2				2	
H3471	018	0	1	02	01	H3471_018_0	6	7	POS Group = Acupuncture	10		13a;	2			1	10.00	10.00	2				2	
H3471	018	0	1	02	01	H3471_018_0	6	8	POS Group = Fitness Benefit	10		14c4;	2			2			1	360.00	3		2	
H3471	019	0	1	02	01	H3471_019_0	6	1	POS Group 1 = 30%	11	3-1;3-2;3-4;8a1;8a2;8b1;8b2;14a;15;17b;	14b;	1	30	30	2			2				2	
H3471	019	0	1	02	01	H3471_019_0	6	10	POS Group 10 = $450	01	9a1;9a2;9b;		2			1	450.00	450.00	2				2	
H3471	019	0	1	02	01	H3471_019_0	6	11	POS Group 11 = $360	10		14c4;	2			2			1	360.00	3		2	
H3471	019	0	1	02	01	H3471_019_0	6	12	POS Group 12 = $750	10		16a;16b;	2			2			1	750.00	3		2	
H3471	019	0	1	02	01	H3471_019_0	6	13	POS Group 13 = 20%	01	12;		1	20	20	2			2				2	
H3471	019	0	1	02	01	H3471_019_0	6	14	POS Group 13 = $500	01	10a1;10a2;		2			1	500.00	500.00	2				2	
H3471	019	0	1	02	01	H3471_019_0	6	15	POS Group = $200	10		17b;	2			2			1	200.00	3		2	
H3471	019	0	1	02	01	H3471_019_0	6	2	POS group 2 = 50%	01	6;11a;11b;11c;		1	50	50	2			2				2	
H3471	019	0	1	02	01	H3471_019_0	6	3	POS Group 3 = $0	11	7k;9d;14d;14e1;14e2;14e3;14e4;14e5;	14c7;	2			2			2				2	
H3471	019	0	1	02	01	H3471_019_0	6	4	POS Group 4 = $10-$65	11	3-3;7b;7c;7d;7f;7g;7i;17a;18a;	13a;	2			1	10.00	65.00	2				2	
H3471	019	0	1	02	01	H3471_019_0	6	5	POS Group 5 = $20	01	8b3;		2			1	20.00	20.00	2				2	
H3471	019	0	1	02	01	H3471_019_0	6	6	POS Group 6 = $25	01	7a;		2			1	25.00	25.00	2				2	
H3471	019	0	1	02	01	H3471_019_0	6	7	POS group 7 = $40	01	7e;7h;9c;		2			1	40.00	40.00	2				2	
H3471	019	0	1	02	01	H3471_019_0	6	8	POS Group 8 = $50	01	16b;		2			1	50.00	50.00	2				2	
H3471	019	0	1	02	01	H3471_019_0	6	9	POS Group 9 = $75	01	5;		2			1	75.00	75.00	2				2	
H3471	804	0	1	02	01	H3471_804_0	3	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H3471	804	0	1	02	01	H3471_804_0	3	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3471	805	0	1	02	01	H3471_805_0	3	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H3471	805	0	1	02	01	H3471_805_0	3	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3471	806	0	1	02	01	H3471_806_0	3	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H3471	806	0	1	02	01	H3471_806_0	3	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3528	003	0	1	02	01	H3528_003_0	7	1	Dental	10		16a;16b;	1	0	50	2			1	3000.00	3		1	100.00
H3528	010	0	1	02	01	H3528_010_0	12	1	Dental	10		16a;16b;	2			2			2				2	
H3528	011	1	1	02	01	H3528_011_1	10	1	$0	11	14a;14e1;14e2;14e3;14e4;14e5;	14b;	2			2			2				2	
H3528	011	1	1	02	01	H3528_011_1	10	2	20%	01	10a2;12;		1	20	20	2			2				2	
H3528	011	1	1	02	01	H3528_011_1	10	3	$325	01	10a1;		2			1	325.00	325.00	2				2	
H3528	011	1	1	02	01	H3528_011_1	10	4	$35 to 35%	01	15;		1	35	35	1	35.00	35.00	2				2	
H3528	011	1	1	02	01	H3528_011_1	10	5	35%	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14d;16b;18a;	9d_2;18a;	1	35	35	2			2				2	
H3528	011	1	1	02	01	H3528_011_1	10	6	Dental	10		16a;	2			2			2				2	
H3528	011	2	1	02	01	H3528_011_2	11	1	$0	11	14a;14e1;14e2;14e3;14e4;14e5;	14b;	2			2			2				2	
H3528	011	2	1	02	01	H3528_011_2	11	2	20%	01	10a2;12;		1	20	20	2			2				2	
H3528	011	2	1	02	01	H3528_011_2	11	3	$325	01	10a1;		2			1	325.00	325.00	2				2	
H3528	011	2	1	02	01	H3528_011_2	11	4	$35 to 35%	01	15;		1	35	35	1	35.00	35.00	2				2	
H3528	011	2	1	02	01	H3528_011_2	11	5	35%	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14d;16b;18a;	9d_2;18a;	1	35	35	2			2				2	
H3528	011	2	1	02	01	H3528_011_2	11	6	Dental	10		16a;	2			2			2				2	
H3528	014	0	1	02	01	H3528_014_0	12	1	Dental	10		16a;16b;	2			2			2				2	
H3528	015	0	1	02	01	H3528_015_0	10	1	40%	01	5;6;7e;7h;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;11a;11b;		1	40	40	2			2				2	
H3528	015	0	1	02	01	H3528_015_0	10	2	$0	11	14a;14e1;14e2;14e3;14e4;14e5;	14b;	2			2			2				2	
H3528	015	0	1	02	01	H3528_015_0	10	3	20%	11	9d;10a2;12;14d;	9d_2;	1	20	20	2			2				2	
H3528	015	0	1	02	01	H3528_015_0	10	4	$300	01	10a1;		2			1	300.00	300.00	2				2	
H3528	015	0	1	02	01	H3528_015_0	10	5	50%	01	3-2;		1	50	50	2			2				2	
H3528	015	0	1	02	01	H3528_015_0	10	6	$50	11	3-1;3-3;3-4;7a;7b;7c;7d;7f;7g;7i;16b;18a;	18a;	2			1	50.00	50.00	2				2	
H3528	015	0	1	02	01	H3528_015_0	10	7	30%	01	11c;		1	30	30	2			2				2	
H3528	015	0	1	02	01	H3528_015_0	10	8	$35 to 40%	01	15;		1	40	40	1	35.00	35.00	2				2	
H3528	015	0	1	02	01	H3528_015_0	10	9	Dental				2			2			2				2	
H3528	016	0	1	02	01	H3528_016_0	10	1	Dental	10		16a;16b;	2			2			2				2	
H3528	806	0	1	02	01	H3528_806_0	5	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H3528	806	0	1	02	01	H3528_806_0	5	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3528	807	0	1	02	01	H3528_807_0	5	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H3528	807	0	1	02	01	H3528_807_0	5	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3551	003	0	1	02	01	H3551_003_0	6	1	50% Coinsurance	01	3-1;3-2;3-3;3-4;5;6;7b;7c;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	50	50	2			2				2	
H3551	003	0	1	02	01	H3551_003_0	6	2	$0	01	7a;		2			2			2				2	
H3551	003	0	1	02	01	H3551_003_0	6	3	$25 Copay	01	7d;		2			1	25.00	25.00	2				2	
H3597	011	0	1	02	01	H3597_011_0	8	1	Dental POS	10		16a;16b;	2			1	0.00	0.00	2				2	
H3597	012	0	1	02	01	H3597_012_0	8	1	Dental POS	10		16a;16b;	2			1	0.00	0.00	2				2	
H3653	004	0	1	02	01	H3653_004_0	9	1	Dental-5000	10		16b;	1	30	30	2			2				2	
H3653	004	0	1	02	01	H3653_004_0	9	2	Non Medicare Eye Exam	10		17a;	2			1	30.00	30.00	2				2	
H3653	004	0	1	02	01	H3653_004_0	9	3	Non Medicare Eyewear OON	10		17b;	2			1	100.00	100.00	2				2	
H3653	004	0	1	02	01	H3653_004_0	9	4	Dental Prev OON - 30%	10		16a;	1	30	30	2			2				2	
H3653	004	0	1	02	01	H3653_004_0	9	5	Comp Dental Med -  30%	01	16b;		1	30	30	2			2				2	
H3653	004	0	1	02	01	H3653_004_0	9	6	Eyewear Medicare	01	17b;		2			1	25.00	100.00	2				2	
H3653	004	0	1	02	01	H3653_004_0	9	7	Medicare Eye Exam	01	17a;		2			1	35.00	35.00	2				2	
H3653	015	0	1	02	01	H3653_015_0	8	1	Dental 2500	11	16b;	16b;	1	30	30	2			2				2	
H3653	015	0	1	02	01	H3653_015_0	8	2	Non Medicare Eye Exam	10		17a;	2			1	30.00	30.00	2				2	
H3653	015	0	1	02	01	H3653_015_0	8	3	Non Medicare Eyewear OON	10		17b;	2			1	100.00	100.00	2				2	
H3653	015	0	1	02	01	H3653_015_0	8	4	Dental Prev OON - 30%	10		16a;	1	30	30	2			2				2	
H3653	015	0	1	02	01	H3653_015_0	8	5	Eyewear Medicare OON	01	17b;		2			1	25.00	100.00	2				2	
H3653	015	0	1	02	01	H3653_015_0	8	6	Medicare Eye Exam	01	17a;		2			1	35.00	35.00	2				2	
H3653	018	0	1	02	01	H3653_018_0	5	1	Non Medicare Eye Exam OON	10		17a;	2			1	30.00	30.00	2				2	
H3653	018	0	1	02	01	H3653_018_0	5	2	Non Medicare Eyewear OON	10		17b;	2			1	100.00	100.00	2				2	
H3653	018	0	1	02	01	H3653_018_0	5	3	Dental-2000	11	16b;	16b;	1	30	30	2			2				2	
H3653	018	0	1	02	01	H3653_018_0	5	4	Dental Prev OON - 30%	10		16a;	1	30	30	2			2				2	
H3653	018	0	1	02	01	H3653_018_0	5	5	Eyewear Medicare OON	01	17b;		2			1	25.00	100.00	2				2	
H3653	018	0	1	02	01	H3653_018_0	5	6	Medicare Eye Exam OON	01	17a;		2			1	35.00	35.00	2				2	
H3653	022	0	1	02	01	H3653_022_0	8	1	Dental 2500	11	16b;	16b;	1	30	30	2			2				2	
H3653	022	0	1	02	01	H3653_022_0	8	2	Non Medicare Eye Exam	10		17a;	2			1	30.00	30.00	2				2	
H3653	022	0	1	02	01	H3653_022_0	8	3	Non Medicare Eyewear OON	10		17b;	2			1	100.00	100.00	2				2	
H3653	022	0	1	02	01	H3653_022_0	8	4	Dental Prev OON - 30%	10		16a;	1	30	30	2			2				2	
H3653	022	0	1	02	01	H3653_022_0	8	5	Eyewear Medicare	01	17b;		2			1	25.00	100.00	2				2	
H3653	022	0	1	02	01	H3653_022_0	8	6	Medicare Eye Exam	01	17a;		2			1	35.00	35.00	2				2	
H3653	024	0	1	02	01	H3653_024_0	9	1	Dental- 2500	11	16b;	16b;	1	30	30	2			2				2	
H3653	024	0	1	02	01	H3653_024_0	9	2	Non Medicare Eye Exam	10		17a;	2			1	30.00	30.00	2				2	
H3653	024	0	1	02	01	H3653_024_0	9	3	Non Medicare Eyewear OON	10		17b;	2			1	100.00	100.00	2				2	
H3653	024	0	1	02	01	H3653_024_0	9	4	Dental Prev OON - 30%	10		16a;	1	30	30	2			2				2	
H3653	024	0	1	02	01	H3653_024_0	9	5	Eyewear Medicare	01	17b;		2			1	25.00	100.00	2				2	
H3653	024	0	1	02	01	H3653_024_0	9	6	Medicare Eye Exam	01	17a;		2			1	35.00	35.00	2				2	
H3653	026	0	1	02	01	H3653_026_0	8	1	Dental-2500	10		16b;	1	30	30	2			2				2	
H3653	026	0	1	02	01	H3653_026_0	8	2	Non Medicare Eye Exam	10		17a;	2			1	30.00	30.00	2				2	
H3653	026	0	1	02	01	H3653_026_0	8	3	Non Medicare Eyewear OON	10		17b;	2			1	100.00	100.00	2				2	
H3653	026	0	1	02	01	H3653_026_0	8	4	Prev Dental OON	10		16a;	1	30	30	2			2				2	
H3653	026	0	1	02	01	H3653_026_0	8	5	Comp Med Dental 30%	01	16b;		1	30	30	2			2				2	
H3653	026	0	1	02	01	H3653_026_0	8	6	Eyewear Medicare	01	17b;		2			1	25.00	100.00	2				2	
H3653	026	0	1	02	01	H3653_026_0	8	7	Medicare Eye Exam	01	17a;		2			1	35.00	35.00	2				2	
H3653	027	0	1	02	01	H3653_027_0	8	1	Dental-2500	10		16a;16b;	1	30	30	2			2				2	
H3653	027	0	1	02	01	H3653_027_0	8	2	Non Medicare Eye Exam	10		17a;	2			1	30.00	30.00	2				2	
H3653	027	0	1	02	01	H3653_027_0	8	3	Non Medicare EyeWear OON	10		17b;	2			1	100.00	100.00	2				2	
H3653	027	0	1	02	01	H3653_027_0	8	4	Comp Dental	01	16b;		1	30	30	2			2				2	
H3653	027	0	1	02	01	H3653_027_0	8	5	Eyewear Medicare	01	17b;		2			1	25.00	100.00	2				2	
H3653	027	0	1	02	01	H3653_027_0	8	6	Medicare Eye Exam	01	17a;		2			1	35.00	35.00	2				2	
H3660	028	0	1	02	01	H3660_028_0	7	1	20% Coinsurance	01	6;9a1;9a2;9b;9d;12;		1	20	20	2			2				2	
H3660	028	0	1	02	01	H3660_028_0	7	2	$20 Copayment	01	7a;14a;14d;14e1;14e2;14e3;14e4;14e5;		2			1	20.00	20.00	2				2	
H3660	028	0	1	02	01	H3660_028_0	7	3	$40 Copayment	11	3-1;3-2;3-3;3-4;5;7b;7c;7d;7e;7f;7g;7h;7i;7k;9c;16b;17a;18a;	17a;18a;	2			1	40.00	40.00	2				2	
H3660	028	0	1	02	01	H3660_028_0	7	4	$200 Copayment	01	10a1;10a2;		2			1	200.00	200.00	2				2	
H3660	028	0	1	02	01	H3660_028_0	7	5	30% Coinsurance	01	8a1;8a2;8b1;8b2;8b3;11a;11b;11c;15;17b;		1	30	30	2			2				2	
H3660	028	0	1	02	01	H3660_028_0	7	6	Eyewear Allowance	10		17b;	2			2			1	300.00	3		2	
H3660	029	0	1	02	01	H3660_029_0	7	1	20% Coinsurance	01	6;9a1;9a2;9b;9d;12;		1	20	20	2			2				2	
H3660	029	0	1	02	01	H3660_029_0	7	2	$55 Copayment	11	3-1;3-2;3-3;3-4;5;7b;7c;7d;7e;7f;7g;7h;7i;7k;9c;16b;17a;18a;	17a;18a;	2			1	55.00	55.00	2				2	
H3660	029	0	1	02	01	H3660_029_0	7	3	$200 Copayment	01	10a1;10a2;		2			1	200.00	200.00	2				2	
H3660	029	0	1	02	01	H3660_029_0	7	4	30% Coinsurance	01	8a1;8a2;8b1;8b2;8b3;11a;11b;11c;15;17b;		1	30	30	2			2				2	
H3660	029	0	1	02	01	H3660_029_0	7	5	$20 Copayment	01	7a;14a;14d;14e1;14e2;14e3;14e4;14e5;		2			1	20.00	20.00	2				2	
H3660	029	0	1	02	01	H3660_029_0	7	6	Eyewear Allowance	10		17b;	2			2			1	305.00	3		2	
H3660	805	0	1	02	01	H3660_805_0	3	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H3660	805	0	1	02	01	H3660_805_0	3	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3660	806	0	1	02	01	H3660_806_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H3660	806	0	1	02	01	H3660_806_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3664	014	0	1	02	01	H3664_014_0	10	1	Outpatient Diagnostic Labs	01	8a2;		2			1	0.00	35.00	2				2	
H3664	014	0	1	02	01	H3664_014_0	10	2	Dental	10		16a;16b;	2			2			1	1100.00	3		2	
H3664	014	0	1	02	01	H3664_014_0	10	3	Vision Eye Exam	10		17a;	2			2			2				2	
H3664	014	0	1	02	01	H3664_014_0	10	4	Vision Eye Wear	10		17b;	2			2			1	300.00	3		2	
H3664	014	0	1	02	01	H3664_014_0	10	5	Hearing Exams	10		18a;	2			2			2				2	
H3664	014	0	1	02	01	H3664_014_0	10	6	Hearing Aids	10		18b;	2			2			1	100.00	1		2	
H3664	017	0	1	02	01	H3664_017_0	13	1	Outpatient Diagnostic Labs	01	8a2;		2			1	0.00	5.00	2				2	
H3664	017	0	1	02	01	H3664_017_0	13	2	Dental	10		16a;16b;	2			2			1	1150.00	3		2	
H3664	017	0	1	02	01	H3664_017_0	13	3	Vision Eye Exam	10		17a;	2			2			2				2	
H3664	017	0	1	02	01	H3664_017_0	13	4	Vision Eye Wear	10		17b;	2			2			1	300.00	3		2	
H3664	017	0	1	02	01	H3664_017_0	13	5	Hearing Exams	10		18a;	2			2			2				2	
H3664	017	0	1	02	01	H3664_017_0	13	6	Hearing Aids	10		18b;	2			2			1	100.00	1		2	
H3664	020	0	1	02	01	H3664_020_0	13	1	Outpatient Diagnostic Labs	01	8a2;		2			1	0.00	5.00	2				2	
H3664	020	0	1	02	01	H3664_020_0	13	2	Dental	10		16a;16b;	2			2			1	850.00	3		2	
H3664	020	0	1	02	01	H3664_020_0	13	3	Vision Eye Exam	10		17a;	2			2			2				2	
H3664	020	0	1	02	01	H3664_020_0	13	4	Vision Eye Wear	10		17b;	2			2			1	300.00	3		2	
H3664	020	0	1	02	01	H3664_020_0	13	5	Hearing Exams	10		18a;	2			1	5.00	5.00	2				2	
H3664	020	0	1	02	01	H3664_020_0	13	6	Hearing Aids	10		18b;	2			2			1	100.00	1		2	
H3664	021	0	1	02	01	H3664_021_0	13	1	Outpatient Diagnostic Labs	01	8a2;		2			1	0.00	5.00	2				2	
H3664	021	0	1	02	01	H3664_021_0	13	2	Dental	10		16a;16b;	2			2			1	600.00	3		2	
H3664	021	0	1	02	01	H3664_021_0	13	3	Vision Eye Exam	10		17a;	2			2			2				2	
H3664	021	0	1	02	01	H3664_021_0	13	4	Vision Eye Wear	10		17b;	2			2			1	300.00	3		2	
H3664	021	0	1	02	01	H3664_021_0	13	5	Hearing Exams	10		18a;	2			1	25.00	25.00	2				2	
H3664	021	0	1	02	01	H3664_021_0	13	6	Hearing Aids	10		18b;	2			2			1	100.00	1		2	
H3664	023	0	1	02	01	H3664_023_0	13	1	Outpatient Diagnostic Labs	01	8a2;		2			1	0.00	5.00	2				2	
H3664	023	0	1	02	01	H3664_023_0	13	2	Dental	10		16a;16b;	2			2			1	600.00	3		2	
H3664	023	0	1	02	01	H3664_023_0	13	3	Vision Eye Exam	10		17a;	2			2			2				2	
H3664	023	0	1	02	01	H3664_023_0	13	4	Vision Eye Wear	10		17b;	2			2			1	300.00	3		2	
H3664	023	0	1	02	01	H3664_023_0	13	5	Hearing Exams	10		18a;	2			1	25.00	25.00	2				2	
H3664	023	0	1	02	01	H3664_023_0	13	6	Hearing Aids	10		18b;	2			2			1	100.00	1		2	
H3664	801	0	1	02	01	H3664_801_0	4	1		01	6;14a;		2			2								
H3664	802	0	1	02	01	H3664_802_0	4	1		01	6;14a;		2			2								
H3664	803	0	1	02	01	H3664_803_0	4	1		01	6;14a;		2			2								
H3664	805	0	2	02	01	H3664_805_0	4	1		01	6;14a;		2			2								
H3664	806	0	2	02	01	H3664_806_0	4	1		01	6;14a;		2			2								
H3664	807	0	1	02	01	H3664_807_0	4	1		01	6;14a;		2			2								
H3706	009	0	1	02	01	H3706_009_0	2	1	OON Physician	01	7d;7g;		2			1	55.00	55.00	2				2	
H3706	009	0	1	02	01	H3706_009_0	2	2	Zero Dollar	01	7k;		2			2			2				2	
H3706	009	0	1	02	01	H3706_009_0	2	3	20%	01	10a2;12;		1	20	20	2			2				2	
H3706	009	0	1	02	01	H3706_009_0	2	4	Ambulance	01	10a1;		2			1	240.00	240.00	2				2	
H3748	001	0	1	02	01	H3748_001_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3748	003	0	1	02	01	H3748_003_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3748	004	0	1	02	01	H3748_004_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3748	006	0	1	02	01	H3748_006_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3748	007	0	1	02	01	H3748_007_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3748	008	0	1	02	01	H3748_008_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3748	009	0	1	02	01	H3748_009_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3748	010	0	1	02	01	H3748_010_0	7	1	0% coinsurance	10		16a;	1	0	0	2			2				2	
H3748	013	0	1	02	01	H3748_013_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3749	001	0	1	02	01	H3749_001_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3749	001	0	1	02	01	H3749_001_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H3749	017	0	1	02	01	H3749_017_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3749	017	0	1	02	01	H3749_017_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H3749	018	0	1	02	01	H3749_018_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3749	018	0	1	02	01	H3749_018_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H3749	020	0	1	02	01	H3749_020_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3749	020	0	1	02	01	H3749_020_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H3794	002	0	1	02	01	H3794_002_0	3	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H3794	004	0	1	02	01	H3794_004_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3794	004	0	1	02	01	H3794_004_0	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H3805	001	0	1	02	01	H3805_001_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3805	001	0	1	02	01	H3805_001_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H3805	015	0	1	02	01	H3805_015_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3805	017	0	1	02	01	H3805_017_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3805	032	0	1	02	01	H3805_032_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3805	032	0	1	02	01	H3805_032_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H3805	033	0	1	02	01	H3805_033_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3805	033	0	1	02	01	H3805_033_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H3805	034	0	1	02	01	H3805_034_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3805	034	0	1	02	01	H3805_034_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H3805	035	0	1	02	01	H3805_035_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3805	035	0	1	02	01	H3805_035_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H3805	037	0	1	02	01	H3805_037_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3805	039	1	1	02	01	H3805_039_1	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3805	039	1	1	02	01	H3805_039_1	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H3805	039	2	1	02	01	H3805_039_2	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H3805	039	2	1	02	01	H3805_039_2	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H3815	016	0	1	02	01	H3815_016_0	17	1																
H3815	026	0	1	02	01	H3815_026_0	14	1	$35 copay	01	7a;7d;		2			1	35.00	35.00	2				2	
H3822	007	0	1	02	01	H3822_007_0	6	1	40% Coinsurance	01	3-1;3-2;3-3;3-4;5;6;7b;7c;7e;7f;7h;7i;8a2;8b2;8b3;9a1;9a2;9b;9c;9d;12;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	40	40	2			2				2	
H3822	007	0	1	02	01	H3822_007_0	6	2	$75.00 Copay	01	7d;7g;7k;		2			1	75.00	75.00	2				2	
H3822	007	0	1	02	01	H3822_007_0	6	3	$60.00 Copay	01	7a;14a;		2			1	60.00	60.00	2				2	
H3822	007	0	1	02	01	H3822_007_0	6	4	20% Coinsurance	01	11a;11b;11c;		1	20	20	2			2				2	
H3822	007	0	1	02	01	H3822_007_0	6	5	$0 Copay	10		16a;	2			1	0.00	0.00	2				2	
H3822	007	0	1	02	01	H3822_007_0	6	6	Medicare Part B Rx Drugs	01	15;		1	40	40	2			2				2	
H3822	007	0	1	02	01	H3822_007_0	6	7	Comprehensive Dental	10		16b;	1	50	50	2			2				2	
H3822	007	0	1	02	01	H3822_007_0	6	8	8a1 Cost Share Group	01	8a1;		1	40	40	1	60.00	60.00	2				2	
H3822	007	0	1	02	01	H3822_007_0	6	9	8b1 Cost Share Group	01	8b1;		1	40	40	1	60.00	60.00	2				2	
H3822	008	0	1	02	01	H3822_008_0	6	1	40% Coinsurance	01	3-1;3-2;3-3;3-4;5;6;7b;7c;7e;7f;7h;7i;8a2;8b2;8b3;9a1;9a2;9b;9c;9d;12;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	40	40	2			2				2	
H3822	008	0	1	02	01	H3822_008_0	6	2	$0 Copay	10		16a;	2			1	0.00	0.00	2				2	
H3822	008	0	1	02	01	H3822_008_0	6	3	$60 Copay	01	7a;14a;		2			1	60.00	60.00	2				2	
H3822	008	0	1	02	01	H3822_008_0	6	4	20% Coinsurance	01	11a;11b;11c;		1	20	20	2			2				2	
H3822	008	0	1	02	01	H3822_008_0	6	5	$75 Copay	01	7d;7g;7k;		2			1	75.00	75.00	2				2	
H3822	008	0	1	02	01	H3822_008_0	6	6	Comprehensive Dental	10		16b;	1	50	50	2			2				2	
H3822	008	0	1	02	01	H3822_008_0	6	7	8a1 Cost Share Group	01	8a1;		1	40	40	1	60.00	60.00	2				2	
H3822	008	0	1	02	01	H3822_008_0	6	8	8b1 Cost Share Group	01	8b1;		1	40	40	1	60.00	60.00	2				2	
H3822	008	0	1	02	01	H3822_008_0	6	9	Medicare Part B Rx Drugs	01	15;		1	40	40	2			2				2	
H3864	002	0	1	02	01	H3864_002_0	4	1	30% Coinsurance	11	3-1;3-2;3-3;3-4;5;6;7b;7e;7f;7h;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;18a;	13d;14b;	1	30	30	2			2				2	
H3864	002	0	1	02	01	H3864_002_0	4	10	Hearing Aids	10		18b;	2			1	599.00	999.00	2				2	
H3864	002	0	1	02	01	H3864_002_0	4	11	Meal Benefit	10		13c;	2			2			2				2	
H3864	002	0	1	02	01	H3864_002_0	4	12	Embedded Preventive Dental	10		16a;	2			2			1	1000.00	3		2	
H3864	002	0	1	02	01	H3864_002_0	4	13	Embedded Comprehensive Dental	10		16b;	1	50	50	2			1	1000.00	3		2	
H3864	002	0	1	02	01	H3864_002_0	4	14	7g Other Health Care Professional Serv	01	7g;		1	30	30	1	45.00	45.00	2				2	
H3864	002	0	1	02	01	H3864_002_0	4	15	OON Select Professional Services	01	7a;7c;7d;7i;		2			1	45.00	45.00	2				2	
H3864	002	0	1	02	01	H3864_002_0	4	16	Medicare Part B Rx Drugs	01	15;		1	30	30	1	35.00	35.00	2				2	
H3864	002	0	1	02	01	H3864_002_0	4	2	Mandatory / Enhanced Benefits	10		13e;14c4;	2			2			2				2	
H3864	002	0	1	02	01	H3864_002_0	4	3	Ambulance Services	01	10a1;10a2;		2			1	300.00	300.00	2				2	
H3864	002	0	1	02	01	H3864_002_0	4	4	Medicare Covered Eyewear	01	17b;		2			2			2				2	
H3864	002	0	1	02	01	H3864_002_0	4	5	Routine Eyewear	10		17b;	2			2			1	250.00	3		2	
H3864	002	0	1	02	01	H3864_002_0	4	6	Routine Hearing Exams	10		18a;18a2;	2			2			2				2	
H3864	002	0	1	02	01	H3864_002_0	4	7	Routine Eye Exams	10		17a;	1	30	30	2			2				2	
H3864	002	0	1	02	01	H3864_002_0	4	8	Over-the-Counter (OTC) Items	10		13b;	2			2			1	100.00	5		2	
H3864	002	0	1	02	01	H3864_002_0	4	9	Alternative Therapies	10		7b;13a;14c17;	2			2			2				2	
H3864	014	0	1	02	01	H3864_014_0	6	1	50% Coinsurance	11	3-1;3-2;3-3;3-4;5;6;7b;7e;7f;7h;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;18a;	13d;14b;	1	50	50	2			2				2	
H3864	014	0	1	02	01	H3864_014_0	6	10	Hearing Aids	10		18b;	2			1	599.00	999.00	2				2	
H3864	014	0	1	02	01	H3864_014_0	6	11	Meal Benefit	10		13c;	2			2			2				2	
H3864	014	0	1	02	01	H3864_014_0	6	12	OON Select Professional Services	01	7a;7c;7d;7g;7i;		1	50	50	1	45.00	45.00	2				2	
H3864	014	0	1	02	01	H3864_014_0	6	13	Embedded Preventive Dental	10		16a;	2			2			1	1500.00	3		2	
H3864	014	0	1	02	01	H3864_014_0	6	14	Embedded Comprehensive Dental	10		16b;	1	50	50	2			1	1500.00	3		2	
H3864	014	0	1	02	01	H3864_014_0	6	15	Medicare Part B Rx Drugs	01	15;		1	50	50	1	35.00	35.00	2				2	
H3864	014	0	1	02	01	H3864_014_0	6	2	Mandatory / Enhanced Benefits	10		13e;14c4;	2			2			2				2	
H3864	014	0	1	02	01	H3864_014_0	6	3	Ambulance Services	01	10a1;10a2;		2			1	300.00	300.00	2				2	
H3864	014	0	1	02	01	H3864_014_0	6	4	Medicare Covered Eyewear	01	17b;		2			2			2				2	
H3864	014	0	1	02	01	H3864_014_0	6	5	Routine Eyewear	10		17b;	2			2			1	200.00	3		2	
H3864	014	0	1	02	01	H3864_014_0	6	6	Routine Hearing Exams	10		18a;18a2;	2			2			2				2	
H3864	014	0	1	02	01	H3864_014_0	6	7	Routine Eye Exams	10		17a;	1	50	50	2			2				2	
H3864	014	0	1	02	01	H3864_014_0	6	8	Over-the-Counter (OTC) Items	10		13b;	2			2			1	25.00	5		2	
H3864	014	0	1	02	01	H3864_014_0	6	9	Alternative Therapies	10		7b;13a;14c17;	2			1	25.00	25.00	2				2	
H3864	024	0	1	02	01	H3864_024_0	5	1	50% Coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;18a;	13d;14b;	1	50	50	2			2				2	
H3864	024	0	1	02	01	H3864_024_0	5	10	Routine Hearing Exam	10		18a;18a2;	2			2			2				2	
H3864	024	0	1	02	01	H3864_024_0	5	11	Meal Benefit	10		13c;	2			2			2				2	
H3864	024	0	1	02	01	H3864_024_0	5	12	Embedded Preventive Dental	10		16a;	2			2			1	1750.00	3		2	
H3864	024	0	1	02	01	H3864_024_0	5	13	Embedded Comprehensive Dental	10		16b;	1	50	50	2			1	1750.00	3		2	
H3864	024	0	1	02	01	H3864_024_0	5	14	Medicare Part B Rx Drugs	01	15;		1	50	50	1	35.00	35.00	2				2	
H3864	024	0	1	02	01	H3864_024_0	5	2	Mandatory / Enhanced Benefits	10		13e;14c4;	2			2			2				2	
H3864	024	0	1	02	01	H3864_024_0	5	3	Ambulance Services	01	10a1;10a2;		2			1	275.00	275.00	2				2	
H3864	024	0	1	02	01	H3864_024_0	5	4	Medicare Covered Eyewear	01	17b;		2			2			2				2	
H3864	024	0	1	02	01	H3864_024_0	5	5	Hearing Aids	10		18b;	2			1	599.00	999.00	2				2	
H3864	024	0	1	02	01	H3864_024_0	5	6	Routine Eyewear	10		17b;	2			2			1	200.00	3		2	
H3864	024	0	1	02	01	H3864_024_0	5	7	Over-the-Counter (OTC) Items	10		13b;	2			2			1	50.00	5		2	
H3864	024	0	1	02	01	H3864_024_0	5	8	Alternative Care	10		7b;13a;	2			1	25.00	25.00	2				2	
H3864	024	0	1	02	01	H3864_024_0	5	9	Routine Eye Exams	10		17a;	1	50	50	2			2				2	
H3864	029	0	1	02	01	H3864_029_0	5	1	50% Coinsurance	11	3-1;3-2;3-3;3-4;5;6;7b;7e;7f;7h;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;18a;	13d;14b;	1	50	50	2			2				2	
H3864	029	0	1	02	01	H3864_029_0	5	10	Meal Benefit	10		13c;	2			2			2				2	
H3864	029	0	1	02	01	H3864_029_0	5	11	Embedded Preventive Dental	10		16a;	2			2			1	1500.00	3		2	
H3864	029	0	1	02	01	H3864_029_0	5	12	Embedded Comprehensive Dental	10		16b;	1	50	50	2			1	1500.00	3		2	
H3864	029	0	1	02	01	H3864_029_0	5	13	Medicare Part B Rx Drugs	01	15;		1	50	50	1	35.00	35.00	2				2	
H3864	029	0	1	02	01	H3864_029_0	5	14	OON Select Professional Services	01	7a;7c;7d;7g;7i;		1	50	50	1	45.00	45.00	2				2	
H3864	029	0	1	02	01	H3864_029_0	5	2	Mandatory / Enhanced Benefits	10		13e;14c4;	2			2			2				2	
H3864	029	0	1	02	01	H3864_029_0	5	3	Ambulance Services	01	10a1;10a2;		2			1	300.00	300.00	2				2	
H3864	029	0	1	02	01	H3864_029_0	5	4	Medicare Covered Eyewear	01	17b;		2			2			2				2	
H3864	029	0	1	02	01	H3864_029_0	5	5	Hearing Aids	10		18b;	2			1	599.00	999.00	2				2	
H3864	029	0	1	02	01	H3864_029_0	5	6	Routine Eyewear	10		17b;	2			2			1	200.00	3		2	
H3864	029	0	1	02	01	H3864_029_0	5	7	Over-the-Counter (OTC) Items	10		13b;	2			2			1	50.00	5		2	
H3864	029	0	1	02	01	H3864_029_0	5	8	Routine Eye Exams	10		17a;	1	50	50	2			2				2	
H3864	029	0	1	02	01	H3864_029_0	5	9	Routine Hearing Exam	10		18a;18a2;	2			2			2				2	
H3864	030	0	1	02	01	H3864_030_0	4	1	30% Coinsurance	11	3-1;3-2;3-3;3-4;5;6;7b;7e;7f;7h;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;18a;	13d;14b;	1	30	30	2			2				2	
H3864	030	0	1	02	01	H3864_030_0	4	10	Hearing Aids	10		18b;	2			1	599.00	999.00	2				2	
H3864	030	0	1	02	01	H3864_030_0	4	11	Meal Benefit	10		13c;	2			2			2				2	
H3864	030	0	1	02	01	H3864_030_0	4	12	OON Select Professional Services	01	7a;7c;7d;7g;7i;		1	30	30	1	45.00	45.00	2				2	
H3864	030	0	1	02	01	H3864_030_0	4	13	Embedded Preventive Dental	10		16a;	2			2			1	2000.00	3		2	
H3864	030	0	1	02	01	H3864_030_0	4	14	Embedded Comprehensive Dental	10		16b;	1	50	50	2			1	2000.00	3		2	
H3864	030	0	1	02	01	H3864_030_0	4	15	Medicare Part B Rx Drugs	01	15;		1	30	30	1	35.00	35.00	2				2	
H3864	030	0	1	02	01	H3864_030_0	4	2	Mandatory / Enhanced Benefits	10		13e;14c4;	2			2			2				2	
H3864	030	0	1	02	01	H3864_030_0	4	3	Ambulance Services	01	10a1;10a2;		2			1	300.00	300.00	2				2	
H3864	030	0	1	02	01	H3864_030_0	4	4	Medicare Covered Eyewear	01	17b;		2			2			2				2	
H3864	030	0	1	02	01	H3864_030_0	4	5	Routine Eyewear	10		17b;	2			2			1	250.00	3		2	
H3864	030	0	1	02	01	H3864_030_0	4	6	Routine Hearing Exams	10		18a;18a2;	2			2			2				2	
H3864	030	0	1	02	01	H3864_030_0	4	7	Routine Eye Exams	10		17a;	1	30	30	2			2				2	
H3864	030	0	1	02	01	H3864_030_0	4	8	Over-the-Counter (OTC) Items	10		13b;	2			2			1	200.00	5		2	
H3864	030	0	1	02	01	H3864_030_0	4	9	Alternative Therapies	10		7b;13a;14c17;	2			2			2				2	
H3864	032	0	1	02	01	H3864_032_0	6	1	50% Coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;18a;	13d;14b;	1	50	50	2			2				2	
H3864	032	0	1	02	01	H3864_032_0	6	10	Routine Hearing Exam	10		18a;18a2;	2			2			2				2	
H3864	032	0	1	02	01	H3864_032_0	6	11	Meal Benefit	10		13c;	2			2			2				2	
H3864	032	0	1	02	01	H3864_032_0	6	12	Embedded Preventive Dental	10		16a;	2			2			1	1500.00	3		2	
H3864	032	0	1	02	01	H3864_032_0	6	13	Embedded Comprehensive Dental	10		16b;	1	50	50	2			1	1500.00	3		2	
H3864	032	0	1	02	01	H3864_032_0	6	14	Medicare Part B Rx Drugs	01	15;		1	50	50	1	35.00	35.00	2				2	
H3864	032	0	1	02	01	H3864_032_0	6	2	Mandatory / Enhanced Benefits	10		13e;14c4;	2			2			2				2	
H3864	032	0	1	02	01	H3864_032_0	6	3	Ambulance Services	01	10a1;10a2;		2			1	350.00	350.00	2				2	
H3864	032	0	1	02	01	H3864_032_0	6	4	Medicare Covered Eyewear	01	17b;		2			2			2				2	
H3864	032	0	1	02	01	H3864_032_0	6	5	Hearing Aids	10		18b;	2			1	599.00	999.00	2				2	
H3864	032	0	1	02	01	H3864_032_0	6	6	Routine Eyewear	10		17b;	2			2			1	200.00	3		2	
H3864	032	0	1	02	01	H3864_032_0	6	7	Over-the-Counter (OTC) Items	10		13b;	2			2			1	50.00	5		2	
H3864	032	0	1	02	01	H3864_032_0	6	8	Alternative Care	10		7b;13a;	2			1	25.00	25.00	2				2	
H3864	032	0	1	02	01	H3864_032_0	6	9	Routine Eye Exams	10		17a;	1	50	50	2			2				2	
H3864	034	0	1	02	01	H3864_034_0	5	1	Mandatory / Enhanced Benefits	10		13e;14c4;	2			2			2				2	
H3864	034	0	1	02	01	H3864_034_0	5	10	Medicare Part B Drugs	01	15;		1	0	20	1	35.00	35.00	2				2	
H3864	034	0	1	02	01	H3864_034_0	5	11	$0 Copay	11	6;7a;8b3;9d;11c;14a;14e1;14e2;14e3;14e4;14e5;17a;17b;	13d;14b;17a;	2			2			2				2	
H3864	034	0	1	02	01	H3864_034_0	5	12	$35 Copay	01	3-1;3-2;5;		2			1	35.00	35.00	2				2	
H3864	034	0	1	02	01	H3864_034_0	5	13	$15 Copay	01	3-3;		2			1	15.00	15.00	2				2	
H3864	034	0	1	02	01	H3864_034_0	5	14	$20 Copay	01	7b;		2			1	20.00	20.00	2				2	
H3864	034	0	1	02	01	H3864_034_0	5	15	$5 Copay	01	7c;7i;		2			1	5.00	5.00	2				2	
H3864	034	0	1	02	01	H3864_034_0	5	16	$0 - $25 Copay	01	7d;7g;		2			1	0.00	25.00	2				2	
H3864	034	0	1	02	01	H3864_034_0	5	17	$30 Copay	01	7e;7h;		2			1	30.00	30.00	2				2	
H3864	034	0	1	02	01	H3864_034_0	5	18	$25 Copay	01	3-4;7f;		2			1	25.00	25.00	2				2	
H3864	034	0	1	02	01	H3864_034_0	5	19	$40 Copay	01	7k;9c;16b;18a;		2			1	40.00	40.00	2				2	
H3864	034	0	1	02	01	H3864_034_0	5	2	Ambulance Services	01	10a1;10a2;		2			1	300.00	300.00	2				2	
H3864	034	0	1	02	01	H3864_034_0	5	20	20% Coinsurance	01	8b2;11a;12;14d;		1	20	20	2			2				2	
H3864	034	0	1	02	01	H3864_034_0	5	21	$0 - $310 Copay	01	8b1;		2			1	0.00	310.00	2				2	
H3864	034	0	1	02	01	H3864_034_0	5	22	$0 - $315 Copay	01	9a1;9a2;9b;		2			1	0.00	315.00	2				2	
H3864	034	0	1	02	01	H3864_034_0	5	23	$0 - $15 Copay, 20% Coinsurance	01	8a1;		1	20	20	1	0.00	15.00	2				2	
H3864	034	0	1	02	01	H3864_034_0	5	24	$0 Copay, 20% Coinsurance	01	8a2;11b;		1	20	20	1	0.00	0.00	2				2	
H3864	034	0	1	02	01	H3864_034_0	5	3	Routine Eyewear	10		17b;	2			2			1	200.00	3		2	
H3864	034	0	1	02	01	H3864_034_0	5	4	Routine Hearing Exams	10		18a;18a2;	2			2			2				2	
H3864	034	0	1	02	01	H3864_034_0	5	5	Over-the-Counter (OTC) Items	10		13b;	2			2			1	75.00	5		2	
H3864	034	0	1	02	01	H3864_034_0	5	6	Alternative Therapies	10		7b;13a;14c17;	2			1	25.00	25.00	2				2	
H3864	034	0	1	02	01	H3864_034_0	5	7	Hearing Aids	10		18b;	2			1	599.00	999.00	2				2	
H3864	034	0	1	02	01	H3864_034_0	5	8	Meal Benefit	10		13c;	2			2			2				2	
H3864	034	0	1	02	01	H3864_034_0	5	9	Embedded Dental	10		16a;16b;	1	50	50	2			1	1500.00	3		2	
H3864	036	0	1	02	01	H3864_036_0	6	1	50% Coinsurance	11	3-1;3-2;3-3;3-4;5;6;7b;7e;7f;7h;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;18a;	13d;14b;	1	50	50	2			2				2	
H3864	036	0	1	02	01	H3864_036_0	6	10	Hearing Aids	10		18b;	2			1	599.00	999.00	2				2	
H3864	036	0	1	02	01	H3864_036_0	6	11	Meal Benefit	10		13c;	2			2			2				2	
H3864	036	0	1	02	01	H3864_036_0	6	12	OON Select Professional Services	01	7a;7c;7d;7g;7i;		1	50	50	1	45.00	45.00	2				2	
H3864	036	0	1	02	01	H3864_036_0	6	13	Embedded Preventive Dental	10		16a;	2			2			1	1500.00	3		2	
H3864	036	0	1	02	01	H3864_036_0	6	14	Embedded Comprehensive Dental	10		16b;	1	50	50	2			1	1500.00	3		2	
H3864	036	0	1	02	01	H3864_036_0	6	15	Medicare Part B Rx Drugs	01	15;		1	50	50	1	35.00	35.00	2				2	
H3864	036	0	1	02	01	H3864_036_0	6	2	Mandatory / Enhanced Benefits	10		13e;14c4;	2			2			2				2	
H3864	036	0	1	02	01	H3864_036_0	6	3	Ambulance Services	01	10a1;10a2;		2			1	350.00	350.00	2				2	
H3864	036	0	1	02	01	H3864_036_0	6	4	Medicare Covered Eyewear	01	17b;		2			2			2				2	
H3864	036	0	1	02	01	H3864_036_0	6	5	Routine Eyewear	10		17b;	2			2			1	200.00	3		2	
H3864	036	0	1	02	01	H3864_036_0	6	6	Routine Hearing Exams	10		18a;18a2;	2			2			2				2	
H3864	036	0	1	02	01	H3864_036_0	6	7	Routine Eye Exams	10		17a;	1	50	50	1	0.00	0.00	2				2	
H3864	036	0	1	02	01	H3864_036_0	6	8	Over-the-Counter (OTC) Items	10		13b;	2			2			1	45.00	5		2	
H3864	036	0	1	02	01	H3864_036_0	6	9	Alternative Therapies	10		7b;13a;14c17;	2			1	25.00	25.00	2				2	
H3864	805	0	1	02	01	H3864_805_0	2	1	Point of Service Group 1	01	6;14a;		1	0	0	2			2				2	
H3864	805	0	1	02	01	H3864_805_0	2	2	Point of Service Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	20	20	2			2				2	
H3864	805	0	1	02	01	H3864_805_0	2	3	Medicare Part B Rx Drugs	01	15;		1	0	20	1	35.00	35.00	2				2	
H3864	806	0	1	02	01	H3864_806_0	2	1	Point of Service Group 1	01	6;14a;		1	0	0	2			2				2	
H3864	806	0	1	02	01	H3864_806_0	2	2	Point of Service Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	20	20	2			2				2	
H3864	806	0	1	02	01	H3864_806_0	2	3	Medicare Part B Rx Drugs	01	15;		1	0	20	1	35.00	35.00	2				2	
H3931	004	0	1	02	01	H3931_004_0	6	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H3931	064	0	1	02	01	H3931_064_0	7	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H3931	070	0	1	02	01	H3931_070_0	6	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H3931	091	0	1	02	01	H3931_091_0	6	1	Dental	10		16a;16b;	1	50	50	2			2				2	
H3931	092	0	1	02	01	H3931_092_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3931	094	0	1	02	01	H3931_094_0	6	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3931	095	0	1	02	01	H3931_095_0	8	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H3931	096	0	1	02	01	H3931_096_0	8	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H3931	097	0	1	02	01	H3931_097_0	8	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H3931	098	0	1	02	01	H3931_098_0	7	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H3931	099	0	1	02	01	H3931_099_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3931	100	0	1	02	01	H3931_100_0	7	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H3931	101	0	1	02	01	H3931_101_0	7	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H3931	102	0	1	02	01	H3931_102_0	6	1	Dental	10		16a;16b;	2			1	0.00	0.00	2				2	
H3931	105	0	1	02	01	H3931_105_0	7	1	20%  Coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3931	107	0	1	02	01	H3931_107_0	7	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H3931	109	0	1	02	01	H3931_109_0	7	1	50% coinsurance				1	50	50	2			2				2	
H3931	109	0	1	02	01	H3931_109_0	7	2	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H3931	124	0	1	02	01	H3931_124_0	7	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H3931	126	0	1	02	01	H3931_126_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3931	129	0	1	02	01	H3931_129_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3931	143	0	1	02	01	H3931_143_0	7	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H3931	145	0	1	02	01	H3931_145_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3931	146	0	1	02	01	H3931_146_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3931	147	0	1	02	01	H3931_147_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3931	148	0	1	02	01	H3931_148_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3931	149	0	1	02	01	H3931_149_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3931	151	0	1	02	01	H3931_151_0	6	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3931	152	0	1	02	01	H3931_152_0	6	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3931	153	0	1	02	01	H3931_153_0	8	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H3931	154	0	1	02	01	H3931_154_0	8	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H3931	156	0	1	02	01	H3931_156_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3931	157	0	1	02	01	H3931_157_0	6	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3931	158	0	1	02	01	H3931_158_0	8	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H3931	160	0	1	02	01	H3931_160_0	6	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3931	161	0	1	02	01	H3931_161_0	8	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H3931	162	0	1	02	01	H3931_162_0	8	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H3931	165	0	1	02	01	H3931_165_0	8	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3931	166	0	1	02	01	H3931_166_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3931	167	0	1	02	01	H3931_167_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3931	168	0	1	02	01	H3931_168_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3931	169	0	1	02	01	H3931_169_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3952	053	0	1	02	01	H3952_053_0	9	1	Point of Service Group 1	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3952	054	0	1	02	01	H3952_054_0	9	1	Point of Service Group 1	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3957	031	0	1	02	01	H3957_031_0	9	1	Specialist Services	01	7b;7d;7f;7g;17a;18a;		2			1	40.00	40.00	2				2	
H3957	031	0	1	02	01	H3957_031_0	9	10	Therapies	01	7c;7e;7h;7i;7k;9c;		2			1	45.00	45.00	2				2	
H3957	031	0	1	02	01	H3957_031_0	9	11	Coinsurance	01	3-1;3-2;3-3;3-4;5;9d;		1	30	30	2			2				2	
H3957	031	0	1	02	01	H3957_031_0	9	12	Preventive Services	11	14a;14d;14e1;14e2;14e3;14e4;14e5;	14b;	2			2			2				2	
H3957	031	0	1	02	01	H3957_031_0	9	13	End Stage Renal Disease	01	12;		1	20	30	2			2				2	
H3957	031	0	1	02	01	H3957_031_0	9	14	Part B	01	15;		1	30	30	2			2				2	
H3957	031	0	1	02	01	H3957_031_0	9	2	PCP	01	7a;		2			2			2				2	
H3957	031	0	1	02	01	H3957_031_0	9	3	Diag Proc & Lab Services	01	8a1;8a2;		2			1	25.00	25.00	2				2	
H3957	031	0	1	02	01	H3957_031_0	9	4	Advanced Imaging	01	8b1;		2			1	225.00	225.00	2				2	
H3957	031	0	1	02	01	H3957_031_0	9	5	X-Ray	01	8b3;		2			1	25.00	25.00	2				2	
H3957	031	0	1	02	01	H3957_031_0	9	6	Outpatient Hospital Services	01	9a1;		2			1	250.00	250.00	2				2	
H3957	031	0	1	02	01	H3957_031_0	9	7	Observation Services	01	9a2;		2			1	250.00	250.00	2				2	
H3957	031	0	1	02	01	H3957_031_0	9	8	ASC	01	9b;		2			1	225.00	225.00	2				2	
H3957	031	0	1	02	01	H3957_031_0	9	9	Therapeutic Radiological Services	01	8b2;		2			1	75.00	75.00	2				2	
H3957	043	1	1	02	01	H3957_043_1	6	1	Specialist Services	01	7b;7d;7f;7g;17a;18a;		2			1	30.00	30.00	2				2	
H3957	043	1	1	02	01	H3957_043_1	6	10	Therapies	01	7c;7e;7h;7i;7k;9c;		2			1	45.00	45.00	2				2	
H3957	043	1	1	02	01	H3957_043_1	6	11	Coinsurance	01	3-1;3-2;3-3;3-4;5;9d;		1	30	30	2			2				2	
H3957	043	1	1	02	01	H3957_043_1	6	12	Preventive Services	11	14a;14d;14e1;14e2;14e3;14e4;14e5;	14b;	2			2			2				2	
H3957	043	1	1	02	01	H3957_043_1	6	13	End Stage Renal Disease	01	12;		1	20	30	2			2				2	
H3957	043	1	1	02	01	H3957_043_1	6	14	Part B	01	15;		1	30	30	2			2				2	
H3957	043	1	1	02	01	H3957_043_1	6	2	PCP	01	7a;		2			2			2				2	
H3957	043	1	1	02	01	H3957_043_1	6	3	Diag Proc & Lab Services	01	8a1;8a2;		2			1	30.00	30.00	2				2	
H3957	043	1	1	02	01	H3957_043_1	6	4	Advanced Imaging	01	8b1;		2			1	175.00	175.00	2				2	
H3957	043	1	1	02	01	H3957_043_1	6	5	X-Ray	01	8b3;		2			1	40.00	40.00	2				2	
H3957	043	1	1	02	01	H3957_043_1	6	6	Outpatient Hospital Services	01	9a1;		2			1	250.00	250.00	2				2	
H3957	043	1	1	02	01	H3957_043_1	6	7	Observation Services	01	9a2;		2			1	250.00	250.00	2				2	
H3957	043	1	1	02	01	H3957_043_1	6	8	ASC	01	9b;		2			1	250.00	250.00	2				2	
H3957	043	1	1	02	01	H3957_043_1	6	9	Therapeutic Radiological Services	01	8b2;		2			1	75.00	75.00	2				2	
H3957	043	2	1	02	01	H3957_043_2	6	1	Specialist Services	01	7b;7d;7f;7g;17a;18a;		2			1	30.00	30.00	2				2	
H3957	043	2	1	02	01	H3957_043_2	6	10	Therapies	01	7c;7e;7h;7i;7k;9c;		2			1	45.00	45.00	2				2	
H3957	043	2	1	02	01	H3957_043_2	6	11	Coinsurance	01	3-1;3-2;3-3;3-4;5;9d;		1	30	30	2			2				2	
H3957	043	2	1	02	01	H3957_043_2	6	12	Preventive Services	11	14a;14d;14e1;14e2;14e3;14e4;14e5;	14b;	2			2			2				2	
H3957	043	2	1	02	01	H3957_043_2	6	13	End Stage Renal Disease	01	12;		1	20	30	2			2				2	
H3957	043	2	1	02	01	H3957_043_2	6	14	Part B	01	15;		1	30	30	2			2				2	
H3957	043	2	1	02	01	H3957_043_2	6	2	PCP	01	7a;		2			2			2				2	
H3957	043	2	1	02	01	H3957_043_2	6	3	Diag Proc & Lab Services	01	8a1;8a2;		2			1	30.00	30.00	2				2	
H3957	043	2	1	02	01	H3957_043_2	6	4	Advanced Imaging	01	8b1;		2			1	175.00	175.00	2				2	
H3957	043	2	1	02	01	H3957_043_2	6	5	X-Ray	01	8b3;		2			1	40.00	40.00	2				2	
H3957	043	2	1	02	01	H3957_043_2	6	6	Outpatient Hospital Services	01	9a1;		2			1	250.00	250.00	2				2	
H3957	043	2	1	02	01	H3957_043_2	6	7	Observation Services	01	9a2;		2			1	250.00	250.00	2				2	
H3957	043	2	1	02	01	H3957_043_2	6	8	ASC	01	9b;		2			1	250.00	250.00	2				2	
H3957	043	2	1	02	01	H3957_043_2	6	9	Therapeutic Radiological Services	01	8b2;		2			1	75.00	75.00	2				2	
H3957	044	1	1	02	01	H3957_044_1	8	1	Specialist Services	01	7b;7d;7f;7g;17a;18a;		2			1	40.00	40.00	2				2	
H3957	044	1	1	02	01	H3957_044_1	8	10	Therapies	01	7c;7e;7h;7i;7k;9c;		2			1	45.00	45.00	2				2	
H3957	044	1	1	02	01	H3957_044_1	8	11	Coinsurance	01	3-1;3-2;3-3;3-4;5;9d;		1	30	30	2			2				2	
H3957	044	1	1	02	01	H3957_044_1	8	12	Preventive Services	11	14a;14d;14e1;14e2;14e3;14e4;14e5;	14b;	2			2			2				2	
H3957	044	1	1	02	01	H3957_044_1	8	13	End Stage Renal Disease	01	12;		1	20	30	2			2				2	
H3957	044	1	1	02	01	H3957_044_1	8	14	Part B	01	15;		1	30	30	2			2				2	
H3957	044	1	1	02	01	H3957_044_1	8	2	PCP	01	7a;		2			2			2				2	
H3957	044	1	1	02	01	H3957_044_1	8	3	Diag Proc & Lab Services	01	8a1;8a2;		2			1	25.00	25.00	2				2	
H3957	044	1	1	02	01	H3957_044_1	8	4	Advanced Imaging	01	8b1;		2			1	225.00	225.00	2				2	
H3957	044	1	1	02	01	H3957_044_1	8	5	X-Ray	01	8b3;		2			1	25.00	25.00	2				2	
H3957	044	1	1	02	01	H3957_044_1	8	6	Outpatient Hospital Services	01	9a1;		2			1	250.00	250.00	2				2	
H3957	044	1	1	02	01	H3957_044_1	8	7	Observation Services	01	9a2;		2			1	250.00	250.00	2				2	
H3957	044	1	1	02	01	H3957_044_1	8	8	ASC	01	9b;		2			1	225.00	225.00	2				2	
H3957	044	1	1	02	01	H3957_044_1	8	9	Therapeutic Radiological Services	01	8b2;		2			1	75.00	75.00	2				2	
H3957	044	4	1	02	01	H3957_044_4	7	1	Specialist Services	01	7b;7d;7f;7g;17a;18a;		2			1	40.00	40.00	2				2	
H3957	044	4	1	02	01	H3957_044_4	7	10	Therapies	01	7c;7e;7h;7i;7k;9c;		2			1	45.00	45.00	2				2	
H3957	044	4	1	02	01	H3957_044_4	7	11	Coinsurance	01	3-1;3-2;3-3;3-4;5;9d;		1	30	30	2			2				2	
H3957	044	4	1	02	01	H3957_044_4	7	12	Preventive Services	11	14a;14d;14e1;14e2;14e3;14e4;14e5;	14b;	2			2			2				2	
H3957	044	4	1	02	01	H3957_044_4	7	13	End Stage Renal Disease	01	12;		1	20	30	2			2				2	
H3957	044	4	1	02	01	H3957_044_4	7	14	Part B	01	15;		1	30	30	2			2				2	
H3957	044	4	1	02	01	H3957_044_4	7	2	PCP	01	7a;		2			2			2				2	
H3957	044	4	1	02	01	H3957_044_4	7	3	Diag Proc & Lab Services	01	8a1;8a2;		2			1	25.00	25.00	2				2	
H3957	044	4	1	02	01	H3957_044_4	7	4	Advanced Imaging	01	8b1;		2			1	225.00	225.00	2				2	
H3957	044	4	1	02	01	H3957_044_4	7	5	X-Ray	01	8b3;		2			1	25.00	25.00	2				2	
H3957	044	4	1	02	01	H3957_044_4	7	6	Outpatient Hospital Services	01	9a1;		2			1	250.00	250.00	2				2	
H3957	044	4	1	02	01	H3957_044_4	7	7	Observation Services	01	9a2;		2			1	250.00	250.00	2				2	
H3957	044	4	1	02	01	H3957_044_4	7	8	ASC	01	9b;		2			1	225.00	225.00	2				2	
H3957	044	4	1	02	01	H3957_044_4	7	9	Therapeutic Radiological Services	01	8b2;		2			1	75.00	75.00	2				2	
H3957	045	1	1	02	01	H3957_045_1	8	1	Specialist Services	01	7b;7d;7f;7g;17a;18a;		2			1	30.00	30.00	2				2	
H3957	045	1	1	02	01	H3957_045_1	8	10	Therapies	01	7c;7e;7h;7i;7k;9c;		2			1	35.00	35.00	2				2	
H3957	045	1	1	02	01	H3957_045_1	8	11	Coinsurance	01	3-1;3-2;3-3;3-4;5;9d;		1	30	30	2			2				2	
H3957	045	1	1	02	01	H3957_045_1	8	12	Preventive Services	11	14a;14d;14e1;14e2;14e3;14e4;14e5;	14b;	2			2			2				2	
H3957	045	1	1	02	01	H3957_045_1	8	13	End Stage Renal Disease	01	12;		1	20	30	2			2				2	
H3957	045	1	1	02	01	H3957_045_1	8	14	Part B	01	15;		1	30	30	2			2				2	
H3957	045	1	1	02	01	H3957_045_1	8	2	PCP	01	7a;		2			2			2				2	
H3957	045	1	1	02	01	H3957_045_1	8	3	Diag Proc & Lab Services	01	8a1;8a2;		2			1	15.00	15.00	2				2	
H3957	045	1	1	02	01	H3957_045_1	8	4	Advanced Imaging	01	8b1;		2			1	175.00	175.00	2				2	
H3957	045	1	1	02	01	H3957_045_1	8	5	X-Ray	01	8b3;		2			1	35.00	35.00	2				2	
H3957	045	1	1	02	01	H3957_045_1	8	6	Outpatient Hospital Services	01	9a1;		2			1	225.00	225.00	2				2	
H3957	045	1	1	02	01	H3957_045_1	8	7	Observation Services	01	9a2;		2			1	225.00	225.00	2				2	
H3957	045	1	1	02	01	H3957_045_1	8	8	ASC	01	9b;		2			1	175.00	175.00	2				2	
H3957	045	1	1	02	01	H3957_045_1	8	9	Therapeutic Radiological Services	01	8b2;		2			1	75.00	75.00	2				2	
H3957	045	2	1	02	01	H3957_045_2	8	1	Specialist Services	01	7b;7d;7f;7g;17a;18a;		2			1	30.00	30.00	2				2	
H3957	045	2	1	02	01	H3957_045_2	8	10	Therapies	01	7c;7e;7h;7i;7k;9c;		2			1	35.00	35.00	2				2	
H3957	045	2	1	02	01	H3957_045_2	8	11	Coinsurance	01	3-1;3-2;3-3;3-4;5;9d;		1	30	30	2			2				2	
H3957	045	2	1	02	01	H3957_045_2	8	12	Preventive Services	11	14a;14d;14e1;14e2;14e3;14e4;14e5;	14b;	2			2			2				2	
H3957	045	2	1	02	01	H3957_045_2	8	13	End Stage Renal Disease	01	12;		1	20	30	2			2				2	
H3957	045	2	1	02	01	H3957_045_2	8	14	Part B	01	15;		1	30	30	2			2				2	
H3957	045	2	1	02	01	H3957_045_2	8	2	PCP	01	7a;		2			2			2				2	
H3957	045	2	1	02	01	H3957_045_2	8	3	Diag Proc & Lab Services	01	8a1;8a2;		2			1	15.00	15.00	2				2	
H3957	045	2	1	02	01	H3957_045_2	8	4	Advanced Imaging	01	8b1;		2			1	175.00	175.00	2				2	
H3957	045	2	1	02	01	H3957_045_2	8	5	X-Ray	01	8b3;		2			1	35.00	35.00	2				2	
H3957	045	2	1	02	01	H3957_045_2	8	6	Outpatient Hospital Services	01	9a1;		2			1	225.00	225.00	2				2	
H3957	045	2	1	02	01	H3957_045_2	8	7	Observation Services	01	9a2;		2			1	225.00	225.00	2				2	
H3957	045	2	1	02	01	H3957_045_2	8	8	ASC	01	9b;		2			1	175.00	175.00	2				2	
H3957	045	2	1	02	01	H3957_045_2	8	9	Therapeutic Radiological Services	01	8b2;		2			1	75.00	75.00	2				2	
H3957	046	1	1	02	01	H3957_046_1	8	1	Specialist Services	01	7b;7d;7f;7g;17a;18a;		2			1	25.00	25.00	2				2	
H3957	046	1	1	02	01	H3957_046_1	8	10	Therapies	01	7c;7e;7h;7i;7k;9c;		2			1	30.00	30.00	2				2	
H3957	046	1	1	02	01	H3957_046_1	8	11	Coinsurance	01	3-1;3-2;3-3;3-4;5;9d;		1	30	30	2			2				2	
H3957	046	1	1	02	01	H3957_046_1	8	12	Preventive Services	11	14a;14d;14e1;14e2;14e3;14e4;14e5;	14b;	2			2			2				2	
H3957	046	1	1	02	01	H3957_046_1	8	13	Part B	01	15;		1	30	30	2			2				2	
H3957	046	1	1	02	01	H3957_046_1	8	2	PCP	01	7a;		2			2			2				2	
H3957	046	1	1	02	01	H3957_046_1	8	3	Diag Proc & Lab Services	01	8a1;8a2;		2			1	15.00	15.00	2				2	
H3957	046	1	1	02	01	H3957_046_1	8	4	Advanced Imaging	01	8b1;		2			1	125.00	125.00	2				2	
H3957	046	1	1	02	01	H3957_046_1	8	5	X-Ray	01	8b3;		2			1	30.00	30.00	2				2	
H3957	046	1	1	02	01	H3957_046_1	8	6	Outpatient Hospital Services	01	9a1;9a2;		2			1	200.00	200.00	2				2	
H3957	046	1	1	02	01	H3957_046_1	8	7	End Stage Renal Disease	01	12;		1	20	30	2			2				2	
H3957	046	1	1	02	01	H3957_046_1	8	8	ASC	01	9b;		2			1	125.00	125.00	2				2	
H3957	046	1	1	02	01	H3957_046_1	8	9	Therapeutic Radiological Services	01	8b2;		2			1	75.00	75.00	2				2	
H3957	046	2	1	02	01	H3957_046_2	8	1	Specialist Services	01	7b;7d;7f;7g;17a;18a;		2			1	25.00	25.00	2				2	
H3957	046	2	1	02	01	H3957_046_2	8	10	Therapies	01	7c;7e;7h;7i;7k;9c;		2			1	30.00	30.00	2				2	
H3957	046	2	1	02	01	H3957_046_2	8	11	Coinsurance	01	3-1;3-2;3-3;3-4;5;9d;		1	30	30	2			2				2	
H3957	046	2	1	02	01	H3957_046_2	8	12	Preventive Services	11	14a;14d;14e1;14e2;14e3;14e4;14e5;	14b;	2			2			2				2	
H3957	046	2	1	02	01	H3957_046_2	8	13	Part B	01	15;		1	30	30	2			2				2	
H3957	046	2	1	02	01	H3957_046_2	8	2	PCP	01	7a;		2			2			2				2	
H3957	046	2	1	02	01	H3957_046_2	8	3	Diag Proc & Lab Services	01	8a1;8a2;		2			1	15.00	15.00	2				2	
H3957	046	2	1	02	01	H3957_046_2	8	4	Advanced Imaging	01	8b1;		2			1	125.00	125.00	2				2	
H3957	046	2	1	02	01	H3957_046_2	8	5	X-Ray	01	8b3;		2			1	30.00	30.00	2				2	
H3957	046	2	1	02	01	H3957_046_2	8	6	Outpatient Hospital Services	01	9a1;9a2;		2			1	200.00	200.00	2				2	
H3957	046	2	1	02	01	H3957_046_2	8	7	End Stage Renal Disease	01	12;		1	20	30	2			2				2	
H3957	046	2	1	02	01	H3957_046_2	8	8	ASC	01	9b;		2			1	125.00	125.00	2				2	
H3957	046	2	1	02	01	H3957_046_2	8	9	Therapeutic Radiological Services	01	8b2;		2			1	75.00	75.00	2				2	
H3957	813	0	1	02	01	H3957_813_0	4	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H3957	813	0	1	02	01	H3957_813_0	4	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3957	814	0	1	02	01	H3957_814_0	4	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H3957	814	0	1	02	01	H3957_814_0	4	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3957	815	0	1	02	01	H3957_815_0	4	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H3957	815	0	1	02	01	H3957_815_0	4	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3957	817	0	1	02	01	H3957_817_0	4	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H3957	817	0	1	02	01	H3957_817_0	4	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H3959	001	0	1	02	01	H3959_001_0	7	1	Dental	10		16a;16b;	1	50	50	2			1	3000.00	3		2	
H3959	002	0	1	02	01	H3959_002_0	7	1	Dental	10		16a;16b;	1	50	50	2			1	3000.00	3		2	
H3959	010	0	1	02	01	H3959_010_0	6	1	20% Coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3959	011	0	1	02	01	H3959_011_0	7	1	20% Coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3959	032	0	1	02	01	H3959_032_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H3959	033	0	1	02	01	H3959_033_0	7	1	Dental	10		16a;16b;	1	50	50	2			2				2	
H3959	037	0	1	02	01	H3959_037_0	6	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H3959	039	0	1	02	01	H3959_039_0	6	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H3959	041	0	1	02	01	H3959_041_0	3	1	$0	10		16a;16b;	2			1	0.00	0.00	2				2	
H3959	045	0	1	02	01	H3959_045_0	6	1	Dental	10		16a;16b;	1	50	50	2			2				2	
H3959	045	0	1	02	01	H3959_045_0	6	2	$0				2			1	0.00	0.00	2				2	
H3959	046	0	1	02	01	H3959_046_0	8	1	Dental				1	50	50	2			1	3000.00	3		2	
H3959	046	0	1	02	01	H3959_046_0	8	2	$0	10		16a;16b;	2			1	0.00	0.00	2				2	
H3959	047	0	1	02	01	H3959_047_0	8	1	Dental				1	50	50	2			1	3000.00	3		2	
H3959	047	0	1	02	01	H3959_047_0	8	2	$0	10		16a;16b;	2			1	0.00	0.00	2				2	
H3959	049	0	1	02	01	H3959_049_0	7	1	50% coinsurance				1	50	50	2			2				2	
H3959	049	0	1	02	01	H3959_049_0	7	2	$0	10		16a;16b;	2			1	0.00	0.00	2				2	
H3959	051	0	1	02	01	H3959_051_0	6	1	Dental				1	50	50	2			1	3000.00	3		2	
H3959	051	0	1	02	01	H3959_051_0	6	2	$0	10		16a;16b;	2			1	0.00	0.00	2				2	
H3959	052	0	1	02	01	H3959_052_0	6	1	Coinsurance 20%	10		16a;16b;	1	20	20	2			2				2	
H3959	053	0	1	02	01	H3959_053_0	6	1	Dental	10		16a;16b;	1	20	20	2			1	3000.00	3		2	
H3959	055	0	1	02	01	H3959_055_0	7	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H3959	056	0	1	02	01	H3959_056_0	4	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H3959	057	0	1	02	01	H3959_057_0	3	1	Dental	10		16a;16b;	1	50	50	2			1	3000.00	3		2	
H3959	068	0	1	02	01	H3959_068_0	6	1	50% Coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	9d_2;14b;14c3;17a;18a;	1	50	50	2			2				2	
H3959	068	0	1	02	01	H3959_068_0	6	2	$0 Copay	10		14c1;14c4;14c7;	2			1	0.00	0.00	2				2	
H3959	068	0	1	02	01	H3959_068_0	6	3	Wigs	10		14c15;	2			1	0.00	0.00	1	400.00	3		2	
H3959	068	0	1	02	01	H3959_068_0	6	4	Ground and Air Ambulance	01	10a1;10a2;		2			1	320.00	320.00	2				2	
H3959	068	0	1	02	01	H3959_068_0	6	5	Diabetic Supplies 0%-20%	01	11c;		1	0	20	2			2				2	
H3959	068	0	1	02	01	H3959_068_0	6	6	0%-50% Other HCProf 14a Prev	01	7g;14a;		1	0	50	2			2				2	
H3959	068	0	1	02	01	H3959_068_0	6	7	0%	10		16a;	1	0	0	2			2				2	
H4003	019	0	1	02	01	H4003_019_0	5	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	7b;7f_2;16a;16b;17a;17b;18a;18a2;18b;	1	20	20	2			2				2	
H4003	034	0	1	02	01	H4003_034_0	6	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	7b;7f_2;16a;16b;17a;17b;18a;18a2;18b;	1	20	20	2			2				2	
H4003	054	0	1	02	01	H4003_054_0	5	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	7b;7f_2;16a;16b;17a;17b;18a;18a2;18b;	1	20	20	2			2				2	
H4003	055	0	1	02	01	H4003_055_0	6	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	7b;7f_2;16a;16b;17a;17b;18a;18a2;18b;	1	20	20	2			2				2	
H4003	806	0	1	02	01	H4003_806_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4003	806	0	1	02	01	H4003_806_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4003	807	0	1	02	01	H4003_807_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4003	807	0	1	02	01	H4003_807_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4003	820	0	1	02	01	H4003_820_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4003	820	0	1	02	01	H4003_820_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4003	821	0	1	02	01	H4003_821_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4003	821	0	1	02	01	H4003_821_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4003	822	0	1	02	01	H4003_822_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4003	822	0	1	02	01	H4003_822_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4003	823	0	1	02	01	H4003_823_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4003	823	0	1	02	01	H4003_823_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4003	824	0	1	02	01	H4003_824_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4003	824	0	1	02	01	H4003_824_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4003	825	0	1	02	01	H4003_825_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4003	825	0	1	02	01	H4003_825_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4003	826	0	1	02	01	H4003_826_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4003	826	0	1	02	01	H4003_826_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4003	827	0	1	02	01	H4003_827_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4003	827	0	1	02	01	H4003_827_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4003	828	0	1	02	01	H4003_828_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4003	828	0	1	02	01	H4003_828_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4003	829	0	1	02	01	H4003_829_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4003	829	0	1	02	01	H4003_829_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4004	056	0	1	02	01	H4004_056_0	5	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	7b;7f_2;16a;16b;17a;17b;18a;18a2;18b;	1	20	20	2			2				2	
H4004	063	0	1	02	01	H4004_063_0	5	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	7b;7f_2;16a;16b;17a;17b;18a;18a2;18b;	1	20	20	2			2				2	
H4004	065	0	1	02	01	H4004_065_0	5	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	7b;7f_2;16a;16b;17a;17b;18a;18a2;18b;	1	20	20	2			2				2	
H4004	066	0	1	02	01	H4004_066_0	4	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	7b;7f_2;16a;16b;17a;17b;18a;18a2;18b;	1	20	20	2			2				2	
H4004	817	0	1	02	01	H4004_817_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4004	817	0	1	02	01	H4004_817_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4004	818	0	1	02	01	H4004_818_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4004	818	0	1	02	01	H4004_818_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4004	819	0	1	02	01	H4004_819_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4004	819	0	1	02	01	H4004_819_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4004	820	0	1	02	01	H4004_820_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4004	820	0	1	02	01	H4004_820_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4004	822	0	1	02	01	H4004_822_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4004	822	0	1	02	01	H4004_822_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4004	823	0	1	02	01	H4004_823_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4004	823	0	1	02	01	H4004_823_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4004	824	0	1	02	01	H4004_824_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4004	824	0	1	02	01	H4004_824_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4004	825	0	1	02	01	H4004_825_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4004	825	0	1	02	01	H4004_825_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4004	826	0	1	02	01	H4004_826_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4004	826	0	1	02	01	H4004_826_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4004	827	0	1	02	01	H4004_827_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4004	827	0	1	02	01	H4004_827_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4004	828	0	1	02	01	H4004_828_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4004	828	0	1	02	01	H4004_828_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4004	829	0	1	02	01	H4004_829_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4004	829	0	1	02	01	H4004_829_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4007	028	0	1	02	01	H4007_028_0	5	1	Out-of-Network Group 1	01	7a;7c;7d;7g;7i;8a2;		1	20	20	2			2				2	
H4007	833	0	1	02	01	H4007_833_0	4	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4007	833	0	1	02	01	H4007_833_0	4	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4007	834	0	1	02	01	H4007_834_0	4	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4007	834	0	1	02	01	H4007_834_0	4	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4007	835	0	1	02	01	H4007_835_0	6	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4007	835	0	1	02	01	H4007_835_0	6	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4007	836	0	1	02	01	H4007_836_0	5	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4007	836	0	1	02	01	H4007_836_0	5	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4007	837	0	1	02	01	H4007_837_0	6	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4007	837	0	1	02	01	H4007_837_0	6	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4007	838	0	1	02	01	H4007_838_0	5	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H4007	838	0	1	02	01	H4007_838_0	5	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H4094	001	0	1	02	01	H4094_001_0	3	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H4152	007	0	1	02	01	H4152_007_0	7	1	POS Group 1	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	7f_2;17a;18a;	1	20	20	2			2				2	
H4152	007	0	1	02	01	H4152_007_0	7	2	POS Group 2	01	10a1;10a2;		2			1	75.00	75.00	2				2	
H4152	018	0	1	02	01	H4152_018_0	7	1	POS Group 1	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	7f_2;17a;18a;	1	20	20	2			2				2	
H4152	018	0	1	02	01	H4152_018_0	7	2	POS Group 2	01	10a1;10a2;		2			1	150.00	150.00	2				2	
H4152	020	0	1	02	01	H4152_020_0	8	1	POS Group 1	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	7f_2;17a;18a;	1	20	20	2			2				2	
H4152	020	0	1	02	01	H4152_020_0	8	2	POS Group 2	01	10a1;10a2;		2			1	150.00	150.00	2				2	
H4152	815	0	1	02	01	H4152_815_0	3	1	Point of Service Group 1	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	50	50	2			2				2	
H4506	029	0	1	02	01	H4506_029_0	17	1	40%	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	40	40	2			2				2	
H4506	029	0	1	02	01	H4506_029_0	17	2	Insulin/Part B Drugs and Dialysis	01	12;15;		1	0	20	1	35.00	35.00	2				2	
H4513	036	0	1	02	01	H4513_036_0	7	1	Coinsurance	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17b;		1	40	40	2			2				2	
H4513	036	0	1	02	01	H4513_036_0	7	2	Ambulance - Ground	01	10a1;		2			1	255.00	255.00	2				2	
H4513	036	0	1	02	01	H4513_036_0	7	3	Ambulance - Air	01	10a2;18a;		1	20	20	2			2				2	
H4513	036	0	1	02	01	H4513_036_0	7	4	Coinsurance Range	01	17a;		1	0	40	2			2				2	
H4513	084	0	1	02	01	H4513_084_0	7	1	Coinsurance	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17b;18a;		1	30	30	2			2				2	
H4513	084	0	1	02	01	H4513_084_0	7	2	Ambulance - Ground	01	10a1;		2			1	260.00	260.00	2				2	
H4513	084	0	1	02	01	H4513_084_0	7	3	Ambulance - Air	01	10a2;		1	20	20	2			2				2	
H4513	084	0	1	02	01	H4513_084_0	7	4	Coinsurance Range	01	17a;		1	0	30	2			2				2	
H4514	007	0	1	02	01	H4514_007_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4514	007	0	1	02	01	H4514_007_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4514	013	1	1	02	01	H4514_013_1	3	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H4514	013	2	1	02	01	H4514_013_2	3	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H4514	013	3	1	02	01	H4514_013_3	3	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H4514	014	0	1	02	01	H4514_014_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4514	014	0	1	02	01	H4514_014_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4514	015	0	1	02	01	H4514_015_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4514	015	0	1	02	01	H4514_015_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4514	016	0	1	02	01	H4514_016_0	3	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H4514	017	0	1	02	01	H4514_017_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4514	017	0	1	02	01	H4514_017_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4514	018	0	1	02	01	H4514_018_0	3	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H4514	019	0	1	02	01	H4514_019_0	3	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4514	019	0	1	02	01	H4514_019_0	3	2	Group 2	10		16b;	1	0	50	2			2				2	
H4514	021	0	1	02	01	H4514_021_0	3	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H4527	001	0	1	02	01	H4527_001_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4527	001	0	1	02	01	H4527_001_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4527	002	0	1	02	01	H4527_002_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4527	002	0	1	02	01	H4527_002_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4527	003	0	1	02	01	H4527_003_0	3	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4527	003	0	1	02	01	H4527_003_0	3	2	Group 2	10		16b;	1	0	50	2			2				2	
H4527	004	0	1	02	01	H4527_004_0	3	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4527	004	0	1	02	01	H4527_004_0	3	2	Group 2	10		16b;	1	0	50	2			2				2	
H4527	005	0	1	02	01	H4527_005_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4527	005	0	1	02	01	H4527_005_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4527	006	0	1	02	01	H4527_006_0	3	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4527	006	0	1	02	01	H4527_006_0	3	2	Group 2	10		16b;	1	0	50	2			2				2	
H4527	013	0	1	02	01	H4527_013_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4527	013	0	1	02	01	H4527_013_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4527	015	0	1	02	01	H4527_015_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H4527	024	0	1	02	01	H4527_024_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4527	024	0	1	02	01	H4527_024_0	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H4527	037	0	1	02	01	H4527_037_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4527	037	0	1	02	01	H4527_037_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H4527	039	0	1	02	01	H4527_039_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4527	039	0	1	02	01	H4527_039_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4527	040	0	1	02	01	H4527_040_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4527	040	0	1	02	01	H4527_040_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4527	041	0	1	02	01	H4527_041_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4527	041	0	1	02	01	H4527_041_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4527	042	0	1	02	01	H4527_042_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4527	042	0	1	02	01	H4527_042_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4527	045	0	1	02	01	H4527_045_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4527	045	0	1	02	01	H4527_045_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4527	048	0	1	02	01	H4527_048_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4527	048	0	1	02	01	H4527_048_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4527	051	0	1	02	01	H4527_051_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4527	051	0	1	02	01	H4527_051_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4604	003	0	1	02	01	H4604_003_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4604	003	0	1	02	01	H4604_003_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4604	005	0	1	02	01	H4604_005_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4604	005	0	1	02	01	H4604_005_0	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H4604	011	0	1	02	01	H4604_011_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4604	011	0	1	02	01	H4604_011_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4604	012	0	1	02	01	H4604_012_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4604	012	0	1	02	01	H4604_012_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4604	013	0	1	02	01	H4604_013_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4604	013	0	1	02	01	H4604_013_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H4604	014	0	1	02	01	H4604_014_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4604	014	0	1	02	01	H4604_014_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4604	015	0	1	02	01	H4604_015_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4604	015	0	1	02	01	H4604_015_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4604	016	0	1	02	01	H4604_016_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4604	016	0	1	02	01	H4604_016_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4604	017	0	1	02	01	H4604_017_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4604	017	0	1	02	01	H4604_017_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4604	018	0	1	02	01	H4604_018_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4604	018	0	1	02	01	H4604_018_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4604	019	0	1	02	01	H4604_019_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4604	019	0	1	02	01	H4604_019_0	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H4604	020	0	1	02	01	H4604_020_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4604	020	0	1	02	01	H4604_020_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4604	022	0	1	02	01	H4604_022_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H4604	022	0	1	02	01	H4604_022_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H4623	001	0	1	02	01	H4623_001_0	12	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	1000.00	3		2	
H4623	002	0	1	02	01	H4623_002_0	6	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	3000.00	3		2	
H4661	001	0	1	02	01	H4661_001_0	7	1	50%	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	50	50	2			2				2	
H4661	001	0	1	02	01	H4661_001_0	7	2	Insulin/Part B Drugs and Dialysis	01	12;15;		1	0	20	1	35.00	35.00	2				2	
H4661	002	0	1	02	01	H4661_002_0	7	1	40%	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	40	40	2			2				2	
H4661	002	0	1	02	01	H4661_002_0	7	2	Insulin/Part B Drugs and Dialysis	01	12;15;		1	0	20	1	35.00	35.00	2				2	
H4661	003	0	1	02	01	H4661_003_0	7	1	40%	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	40	40	2			2				2	
H4661	003	0	1	02	01	H4661_003_0	7	2	Insulin/Part B Drugs and Dialysis	01	12;15;		1	0	20	1	35.00	35.00	2				2	
H4711	001	0	1	02	01	H4711_001_0	6	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H4711	002	0	1	02	01	H4711_002_0	6	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H4711	005	0	1	02	01	H4711_005_0	6	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H4711	006	0	1	02	01	H4711_006_0	7	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H4711	007	0	1	02	01	H4711_007_0	7	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H4711	008	0	1	02	01	H4711_008_0	7	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H4711	009	0	1	02	01	H4711_009_0	7	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H4711	010	0	1	02	01	H4711_010_0	4	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H4835	001	0	1	02	01	H4835_001_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H4835	002	0	1	02	01	H4835_002_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H4835	003	0	1	02	01	H4835_003_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H4835	004	0	1	02	01	H4835_004_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H4835	005	0	1	02	01	H4835_005_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H4835	006	0	1	02	01	H4835_006_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H4847	006	0	1	02	01	H4847_006_0	5	1	30%	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	30	30	2			2				2	
H4847	006	0	1	02	01	H4847_006_0	5	2	Insulin/Part B Drugs and Dialysis	01	12;15;		1	0	20	1	35.00	35.00	2				2	
H4869	001	0	1	02	01	H4869_001_0	11	1	$0 Costshare	11	3-1;3-2;6;7a;7f;8a2;8b3;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;	7f_2;13c;14b;14c1;14c4;14c6;14c8;14c10;14c11;14c13;14c14;14c20;14c21;	2			2			2				2	
H4869	001	0	1	02	01	H4869_001_0	11	10	$0-175 Copay	01	9a1;		2			1	0.00	175.00	2				2	
H4869	001	0	1	02	01	H4869_001_0	11	11	$175 Copay	01	9a2;		2			1	175.00	175.00	2				2	
H4869	001	0	1	02	01	H4869_001_0	11	12	$15-25 Copay	01	9c;		2			1	15.00	25.00	2				2	
H4869	001	0	1	02	01	H4869_001_0	11	13	$200 Copay	01	10a1;		2			1	200.00	200.00	2				2	
H4869	001	0	1	02	01	H4869_001_0	11	14	$25 per month	10		13b;	2			2			1	25.00	7		2	
H4869	001	0	1	02	01	H4869_001_0	11	15	0-20% Coinsurance; $35 Copay	01	15;		1	0	20	1	35.00	35.00	2				2	
H4869	001	0	1	02	01	H4869_001_0	11	16	$ 2500 Flex Card	11	16b;17a;17b;18a;	16a;16b;17a;17b;18a;18a2;18b;	2			2			2				2	
H4869	001	0	1	02	01	H4869_001_0	11	17	$70 Copay	01	5;		2			1	70.00	70.00	2				2	
H4869	001	0	1	02	01	H4869_001_0	11	2	$10 Copay	01	3-3;3-4;7c;7i;		2			1	10.00	10.00	2				2	
H4869	001	0	1	02	01	H4869_001_0	11	3	$75 Copay	01	9b;		2			1	75.00	75.00	2				2	
H4869	001	0	1	02	01	H4869_001_0	11	4	$20 Copay	11	7b;7g;	7b;13a;	2			1	20.00	20.00	2				2	
H4869	001	0	1	02	01	H4869_001_0	11	5	$0-10 Copay	01	7d;		2			1	0.00	10.00	2				2	
H4869	001	0	1	02	01	H4869_001_0	11	6	$10-25 Copay	01	7e;7h;		2			1	10.00	25.00	2				2	
H4869	001	0	1	02	01	H4869_001_0	11	7	$25 Copay	01	7k;		2			1	25.00	25.00	2				2	
H4869	001	0	1	02	01	H4869_001_0	11	8	$50 Copay	01	8a1;8b1;		2			1	50.00	50.00	2				2	
H4869	001	0	1	02	01	H4869_001_0	11	9	20% Coinsurance	11	8b2;9d;10a2;11a;11b;12;	9d_2;	1	20	20	2			2				2	
H4869	002	0	1	02	01	H4869_002_0	9	1	$0 Costshare	11	6;8a2;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;	13c;14b;14c1;14c4;14c6;14c8;14c10;14c11;14c13;14c14;14c20;14c21;	2			2			2				2	
H4869	002	0	1	02	01	H4869_002_0	9	2	20% Coinsurance	11	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;12;	7b;7f_2;9d_2;13a;	1	20	20	2			2				2	
H4869	002	0	1	02	01	H4869_002_0	9	3	0-20% Coinsurance; $35 Copay	01	15;		1	0	20	1	35.00	35.00	2				2	
H4869	002	0	1	02	01	H4869_002_0	9	4	$135 Per Month	10		13b;	2			2			1	135.00	7		2	
H4869	002	0	1	02	01	H4869_002_0	9	5	$4000 Flex Card	11	16b;17a;17b;18a;	16a;16b;17a;17b;18a;18a2;18b;	2			2			2				2	
H4869	003	0	1	02	01	H4869_003_0	10	1	$0 Costshare	11	3-1;3-2;6;7a;7f;8a2;8b3;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;	13c;14b;14c1;14c4;14c6;14c8;14c10;14c11;14c13;14c14;14c20;14c21;	2			2			2				2	
H4869	003	0	1	02	01	H4869_003_0	10	10	$0-175 Copay	01	9a1;		2			1	0.00	175.00	2				2	
H4869	003	0	1	02	01	H4869_003_0	10	11	$175 Copay	01	9a2;		2			1	175.00	175.00	2				2	
H4869	003	0	1	02	01	H4869_003_0	10	12	$15-25 Copay	01	9c;		2			1	15.00	25.00	2				2	
H4869	003	0	1	02	01	H4869_003_0	10	13	$200 Copay	01	10a1;		2			1	200.00	200.00	2				2	
H4869	003	0	1	02	01	H4869_003_0	10	14	$25 per month	10		13b;	2			2			1	25.00	7		2	
H4869	003	0	1	02	01	H4869_003_0	10	15	0-20% Coinsurance; $35 Copay	01	15;		1	0	20	1	35.00	35.00	2				2	
H4869	003	0	1	02	01	H4869_003_0	10	16	$ 2500 Flex Card	11	16b;17a;17b;18a;	16a;16b;17a;17b;18a;18a2;18b;	2			2			2				2	
H4869	003	0	1	02	01	H4869_003_0	10	17	$70 Copay	01	5;		2			1	70.00	70.00	2				2	
H4869	003	0	1	02	01	H4869_003_0	10	2	$10 Copay	01	3-3;3-4;7c;7i;		2			1	10.00	10.00	2				2	
H4869	003	0	1	02	01	H4869_003_0	10	3	$75 Copay	01	9b;		2			1	75.00	75.00	2				2	
H4869	003	0	1	02	01	H4869_003_0	10	4	$20 Copay	11	7b;7g;	7b;13a;	2			1	20.00	20.00	2				2	
H4869	003	0	1	02	01	H4869_003_0	10	5	$0-10 Copay	01	7d;		2			1	0.00	10.00	2				2	
H4869	003	0	1	02	01	H4869_003_0	10	6	$10-25 Copay	01	7e;7h;		2			1	10.00	25.00	2				2	
H4869	003	0	1	02	01	H4869_003_0	10	7	$25 Copay	01	7k;		2			1	25.00	25.00	2				2	
H4869	003	0	1	02	01	H4869_003_0	10	8	$50 Copay	01	8b1;		2			1	50.00	50.00	2				2	
H4869	003	0	1	02	01	H4869_003_0	10	9	20% Coinsurance	11	8a1;8b2;9d;10a2;11a;11b;	9d_2;	1	20	20	2			2				2	
H4869	004	0	1	02	01	H4869_004_0	10	1	$0 Costshare	11	6;8a2;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;	13c;14b;14c1;14c4;14c6;14c8;14c10;14c11;14c13;14c14;14c20;14c21;	2			2			2				2	
H4869	004	0	1	02	01	H4869_004_0	10	2	20% Coinsurance	11	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;12;	7b;7f_2;9d_2;13a;	1	20	20	2			2				2	
H4869	004	0	1	02	01	H4869_004_0	10	3	0-20% Coinsurance; $35 Copay	01	15;		1	0	20	1	35.00	35.00	2				2	
H4869	004	0	1	02	01	H4869_004_0	10	4	$135 Per Month	10		13b;	2			2			1	135.00	7		2	
H4869	004	0	1	02	01	H4869_004_0	10	5	$4000 Flex Card	11	16b;17a;17b;18a;	16a;16b;17a;17b;18a;18a2;18b;	2			2			2				2	
H4869	005	0	1	02	01	H4869_005_0	12	1	$0 Costshare	11	6;7a;7f;8a2;8b3;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;	13c;14b;14c1;14c4;14c6;14c8;14c10;14c11;14c13;14c14;14c20;14c21;	2			2			2				2	
H4869	005	0	1	02	01	H4869_005_0	12	10	$200 Copay	01	10a1;		2			1	200.00	200.00	2				2	
H4869	005	0	1	02	01	H4869_005_0	12	11	$25 per month	10		13b;	2			2			1	25.00	7		2	
H4869	005	0	1	02	01	H4869_005_0	12	12	0-20% Coinsurance; $35 Copay	01	15;		1	0	20	1	35.00	35.00	2				2	
H4869	005	0	1	02	01	H4869_005_0	12	13	$0-225 Copay	01	9a1;		2			1	0.00	225.00	2				2	
H4869	005	0	1	02	01	H4869_005_0	12	14	$150 Copay	01	9b;		2			1	150.00	150.00	2				2	
H4869	005	0	1	02	01	H4869_005_0	12	15	$2000 Flex Card	11	16b;17a;17b;18a;	16a;16b;17a;17b;18a;18a2;18b;	2			2			2				2	
H4869	005	0	1	02	01	H4869_005_0	12	16	$70 Copay	01	5;		2			1	70.00	70.00	2				2	
H4869	005	0	1	02	01	H4869_005_0	12	2	$10 Copay	01	3-1;3-2;7c;7d;7g;7i;		2			1	10.00	10.00	2				2	
H4869	005	0	1	02	01	H4869_005_0	12	3	$20 Copay	11	3-3;3-4;7b;	7b;	2			1	20.00	20.00	2				2	
H4869	005	0	1	02	01	H4869_005_0	12	4	$10-25 Copay	01	7e;7h;		2			1	10.00	25.00	2				2	
H4869	005	0	1	02	01	H4869_005_0	12	5	$25 Copay	01	7k;		2			1	25.00	25.00	2				2	
H4869	005	0	1	02	01	H4869_005_0	12	6	$50 Copay	01	8a1;8b1;		2			1	50.00	50.00	2				2	
H4869	005	0	1	02	01	H4869_005_0	12	7	20% Coinsurance	11	8b2;9d;10a2;11a;12;	9d_2;13a;	1	20	20	2			2				2	
H4869	005	0	1	02	01	H4869_005_0	12	8	$175 Copay	01	9a2;		2			1	175.00	175.00	2				2	
H4869	005	0	1	02	01	H4869_005_0	12	9	$15-25 Copay	01	9c;		2			1	15.00	25.00	2				2	
H4869	009	0	1	02	01	H4869_009_0	11	1	$0 Costshare	01	6;14a;14e1;14e2;14e3;14e4;14e5;		2			2			2				2	
H4869	009	0	1	02	01	H4869_009_0	11	2	20% Coinsurance	11	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;16b;17a;17b;18a;	9d_2;	1	20	20	2			2				2	
H4869	009	0	1	02	01	H4869_009_0	11	3	0-20% Coinsurance; $35 Copay	01	15;		1	0	20	1	35.00	35.00	2				2	
H4869	010	0	1	02	01	H4869_010_0	9	1	$0 Costshare	01	6;14a;14e1;14e2;14e3;14e4;14e5;		2			2			2				2	
H4869	010	0	1	02	01	H4869_010_0	9	2	20% Coinsurance	11	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;16b;17a;17b;18a;	9d_2;	1	20	20	2			2				2	
H4869	010	0	1	02	01	H4869_010_0	9	3	0-20% Coinsurance; $35 Copay	01	15;		1	0	20	1	35.00	35.00	2				2	
H4982	017	0	1	02	01	H4982_017_0	7	1	$0 Copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H4982	018	0	1	02	01	H4982_018_0	7	1	$0 Copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H5008	002	0	1	02	01	H5008_002_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H5008	010	0	1	02	01	H5008_010_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H5008	011	0	1	02	01	H5008_011_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H5008	015	0	1	02	01	H5008_015_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5008	015	0	1	02	01	H5008_015_0	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H5008	016	0	1	02	01	H5008_016_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5008	016	0	1	02	01	H5008_016_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5211	001	0	1	02	01	H5211_001_0	3	1	Preventive, Home Health, Blood	11	3-1;3-2;3-3;3-4;5;6;7a;8a1;8a2;8b2;8b3;9d;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c3;	2			2			2				2	
H5211	001	0	1	02	01	H5211_001_0	3	2	Chiropractic, Therapy	11	7b;7c;7g;7i;	7b;	2			1	20.00	20.00	2				2	
H5211	001	0	1	02	01	H5211_001_0	3	3	Specialist Physician, Podiatry, Hearing	11	7d;7e;7f;7h;9c;18a;	18a;	2			1	25.00	25.00	2				2	
H5211	001	0	1	02	01	H5211_001_0	3	4	Vision	11	17a;	17a;	2			1	0.00	25.00	2				2	
H5211	001	0	1	02	01	H5211_001_0	3	5	Opioid Treatment Services	01	7k;		1	20	20	1	0.00	25.00	2				2	
H5211	001	0	1	02	01	H5211_001_0	3	6	ASC, OP Hospital	01	9a1;9a2;9b;		2			1	0.00	100.00	2				2	
H5211	001	0	1	02	01	H5211_001_0	3	7	High End Imaging	01	8b1;		2			1	150.00	150.00	2				2	
H5211	001	0	1	02	01	H5211_001_0	3	8	Dialysis	01	12;		1	20	20	2			2				2	
H5211	001	0	1	02	01	H5211_001_0	3	9	B Drugs	01	15;		1	0	20	2			2				2	
H5211	002	0	1	02	01	H5211_002_0	5	1	Preventive, Home Health, Blood	11	3-1;3-2;3-3;3-4;5;6;7a;8a2;8b2;9d;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c3;	2			2			2				2	
H5211	002	0	1	02	01	H5211_002_0	5	10	Dialysis	01	12;		1	20	20	2			2				2	
H5211	002	0	1	02	01	H5211_002_0	5	11	Diagnostic Procedures/Tests, X-Rays	01	8a1;8b3;		2			1	5.00	5.00	2				2	
H5211	002	0	1	02	01	H5211_002_0	5	2	Opioid Treatment Services	01	7k;		1	20	20	1	0.00	50.00	2				2	
H5211	002	0	1	02	01	H5211_002_0	5	3	Chiropractic, OP Therapies	11	7b;7c;7g;7i;	7b;	2			1	20.00	20.00	2				2	
H5211	002	0	1	02	01	H5211_002_0	5	4	Outpatient Mental Health	01	7e;7h;		2			1	40.00	40.00	2				2	
H5211	002	0	1	02	01	H5211_002_0	5	5	Specialist Physician, Podiatry, Hearing	11	7d;7f;9c;18a;	18a;	2			1	50.00	50.00	2				2	
H5211	002	0	1	02	01	H5211_002_0	5	6	High End Imaging	01	8b1;		2			1	200.00	200.00	2				2	
H5211	002	0	1	02	01	H5211_002_0	5	7	Vision	11	17a;	17a;	2			1	0.00	50.00	2				2	
H5211	002	0	1	02	01	H5211_002_0	5	8	Part B Drugs	01	15;		1	0	20	2			2				2	
H5211	002	0	1	02	01	H5211_002_0	5	9	ASC, OP Hospital	01	9a1;9a2;9b;		2			1	0.00	200.00	2				2	
H5211	003	0	1	02	01	H5211_003_0	3	1	Preventive, Home Health, Blood	11	3-1;3-2;3-3;3-4;5;6;7a;8a2;8b2;9d;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c3;	2			2			2				2	
H5211	003	0	1	02	01	H5211_003_0	3	10	Dialysis	01	12;		1	20	20	2			2				2	
H5211	003	0	1	02	01	H5211_003_0	3	11	Diagnostic Procedures/Tests, X-Rays	01	8a1;8b3;		2			1	5.00	5.00	2				2	
H5211	003	0	1	02	01	H5211_003_0	3	2	Opioid Treatment Services	01	7k;		1	20	20	1	0.00	50.00	2				2	
H5211	003	0	1	02	01	H5211_003_0	3	3	Chiropractic, OP Therapies	11	7b;7c;7g;7i;	7b;	2			1	20.00	20.00	2				2	
H5211	003	0	1	02	01	H5211_003_0	3	4	Outpatient Mental Health	01	7e;7h;		2			1	40.00	40.00	2				2	
H5211	003	0	1	02	01	H5211_003_0	3	5	Specialist Physician, Podiatry, Hearing	11	7d;7f;9c;18a;	18a;	2			1	50.00	50.00	2				2	
H5211	003	0	1	02	01	H5211_003_0	3	6	High End Imaging	01	8b1;		2			1	200.00	200.00	2				2	
H5211	003	0	1	02	01	H5211_003_0	3	7	Vision	11	17a;	17a;	2			1	0.00	50.00	2				2	
H5211	003	0	1	02	01	H5211_003_0	3	8	Part B Drugs	01	15;		1	0	20	2			2				2	
H5211	003	0	1	02	01	H5211_003_0	3	9	ASC, OP Hospital	01	9a1;9a2;9b;		2			1	0.00	200.00	2				2	
H5211	004	0	1	02	01	H5211_004_0	4	1	Preventive, Home Health, Blood	11	3-1;3-2;3-3;3-4;5;6;7a;8a1;8a2;8b2;8b3;9d;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c3;	2			2			2				2	
H5211	004	0	1	02	01	H5211_004_0	4	2	Chiropractic, Therapy	11	7b;7c;7g;7i;	7b;	2			1	20.00	20.00	2				2	
H5211	004	0	1	02	01	H5211_004_0	4	3	Specialist Physician, Podiatry, Hearing	11	7d;7e;7f;7h;9c;18a;	18a;	2			1	25.00	25.00	2				2	
H5211	004	0	1	02	01	H5211_004_0	4	4	Vision	11	17a;	17a;	2			1	0.00	25.00	2				2	
H5211	004	0	1	02	01	H5211_004_0	4	5	Opioid Treatment Services	01	7k;		1	20	20	1	0.00	25.00	2				2	
H5211	004	0	1	02	01	H5211_004_0	4	6	ASC, OP Hospital	01	9a1;9a2;9b;		2			1	0.00	100.00	2				2	
H5211	004	0	1	02	01	H5211_004_0	4	7	High End Imaging	01	8b1;		2			1	150.00	150.00	2				2	
H5211	004	0	1	02	01	H5211_004_0	4	8	Dialysis	01	12;		1	20	20	2			2				2	
H5211	004	0	1	02	01	H5211_004_0	4	9	B Drugs	01	15;		1	0	20	2			2				2	
H5211	012	0	1	02	01	H5211_012_0	4	1	Preventive, Home Health, Blood	11	3-4;6;7a;9d;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c3;	2			2			2				2	
H5211	012	0	1	02	01	H5211_012_0	4	10	Opioid Treatment Services	01	7k;		1	20	20	1	0.00	50.00	2				2	
H5211	012	0	1	02	01	H5211_012_0	4	11	Part B Drugs	01	15;		1	0	20	2			2				2	
H5211	012	0	1	02	01	H5211_012_0	4	12	Dialysis	01	12;		1	20	20	2			2				2	
H5211	012	0	1	02	01	H5211_012_0	4	13	Cardiac Rehab	01	3-1;		2			1	35.00	35.00	2				2	
H5211	012	0	1	02	01	H5211_012_0	4	14	Labs	01	8a2;		2			1	10.00	10.00	2				2	
H5211	012	0	1	02	01	H5211_012_0	4	2	Hearing Services, Pulmonary Rehab	11	3-3;18a;	18a;	2			1	15.00	15.00	2				2	
H5211	012	0	1	02	01	H5211_012_0	4	3	Chiro, Therapeutic Radiological, X-rays	11	7b;8a1;8b2;8b3;	7b;	2			1	20.00	20.00	2				2	
H5211	012	0	1	02	01	H5211_012_0	4	4	High End Imaging	01	8b1;		2			1	250.00	250.00	2				2	
H5211	012	0	1	02	01	H5211_012_0	4	5	Mental Health,Intensive Cardiac,OT/PT/ST	01	3-2;7c;7e;7h;7i;		2			1	40.00	40.00	2				2	
H5211	012	0	1	02	01	H5211_012_0	4	6	Physician Specialist, Podiatry	01	7d;7f;7g;9c;		2			1	50.00	50.00	2				2	
H5211	012	0	1	02	01	H5211_012_0	4	7	Partial Hospitalization	01	5;		2			1	55.00	55.00	2				2	
H5211	012	0	1	02	01	H5211_012_0	4	8	Vision	11	17a;	17a;	2			1	0.00	50.00	2				2	
H5211	012	0	1	02	01	H5211_012_0	4	9	ASC, OP Hospital	01	9a1;9a2;9b;		2			1	0.00	300.00	2				2	
H5211	013	0	1	02	01	H5211_013_0	4	1	Preventive, Home Health, Blood	11	3-1;3-2;3-3;3-4;5;6;7a;9d;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c3;	2			2			2				2	
H5211	013	0	1	02	01	H5211_013_0	4	10	Dialysis	01	12;		1	20	20	2			2				2	
H5211	013	0	1	02	01	H5211_013_0	4	11	Part B Drugs	01	15;		1	0	20	2			2				2	
H5211	013	0	1	02	01	H5211_013_0	4	2	Lab Services	01	8a2;		2			1	15.00	15.00	2				2	
H5211	013	0	1	02	01	H5211_013_0	4	3	Chiropractic, Therapeutic Rad, X-Ray	11	7b;8a1;8b2;8b3;	7b;	2			1	20.00	20.00	2				2	
H5211	013	0	1	02	01	H5211_013_0	4	4	OP Mental Health, OP Therapies	01	7c;7e;7h;7i;		2			1	40.00	40.00	2				2	
H5211	013	0	1	02	01	H5211_013_0	4	5	Specialist Physician, Podiatry, Hearing	11	7d;7f;9c;18a;	18a;	2			1	50.00	50.00	2				2	
H5211	013	0	1	02	01	H5211_013_0	4	6	High End Imaging	01	8b1;		2			1	200.00	200.00	2				2	
H5211	013	0	1	02	01	H5211_013_0	4	7	Vision, Other Healthcare Professional	11	7g;17a;	17a;	2			1	0.00	50.00	2				2	
H5211	013	0	1	02	01	H5211_013_0	4	8	Opioid Treatment Services	01	7k;		1	20	20	1	0.00	50.00	2				2	
H5211	013	0	1	02	01	H5211_013_0	4	9	ASC, OP Hospital	01	9a1;9a2;9b;		2			1	0.00	250.00	2				2	
H5253	004	0	1	02	01	H5253_004_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	004	0	1	02	01	H5253_004_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	007	0	1	02	01	H5253_007_0	4	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;18a;	7f_2;9d_2;14b;17a;18a;	1	30	30	2			2				2	
H5253	007	0	1	02	01	H5253_007_0	4	2	Group 2	01	10a1;10a2;12;		1	20	20	2			2				2	
H5253	007	0	1	02	01	H5253_007_0	4	3	Group 3	11	7k;8a2;17b;	16a;16b;17b;18b;	2			1	0.00	0.00	2				2	
H5253	007	0	1	02	01	H5253_007_0	4	4	Group 4	01	14a;15;		1	0	30	2			2				2	
H5253	007	0	1	02	01	H5253_007_0	4	5	Group 5	10		13b;14c8;	2			1	0.00	0.00	1	300.00	5		2	
H5253	007	0	1	02	01	H5253_007_0	4	6	Group 6	10		10b1;	1	75	75	2			2				2	
H5253	011	0	1	02	01	H5253_011_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	011	0	1	02	01	H5253_011_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	021	0	1	02	01	H5253_021_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	021	0	1	02	01	H5253_021_0	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	024	0	1	02	01	H5253_024_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H5253	030	0	1	02	01	H5253_030_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	030	0	1	02	01	H5253_030_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	033	0	1	02	01	H5253_033_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	033	0	1	02	01	H5253_033_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	034	0	1	02	01	H5253_034_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	034	0	1	02	01	H5253_034_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	035	0	1	02	01	H5253_035_0	5	1	Group 1	01	7a;		2			1	35.00	35.00	2				2	
H5253	035	0	1	02	01	H5253_035_0	5	10	Group 10	01	14a;15;		1	0	40	2			2				2	
H5253	035	0	1	02	01	H5253_035_0	5	11	Group 11	10		18b;	2			1	99.00	1249.00	2				2	
H5253	035	0	1	02	01	H5253_035_0	5	12	Group 12	10		13b;14c8;	2			1	0.00	0.00	1	40.00	5		2	
H5253	035	0	1	02	01	H5253_035_0	5	13	Group 13	01	7g;		2			1	35.00	70.00	2				2	
H5253	035	0	1	02	01	H5253_035_0	5	14	Group 14	01	5;		2			1	75.00	75.00	2				2	
H5253	035	0	1	02	01	H5253_035_0	5	2	Group 2	11	7b;7c;7d;7f;7i;14e1;17a;18a;	7f_2;17a;18a;	2			1	70.00	70.00	2				2	
H5253	035	0	1	02	01	H5253_035_0	5	3	Group 3	10		16b;	1	0	50	2			2				2	
H5253	035	0	1	02	01	H5253_035_0	5	4	Group 4	01	7e;7h;9c;		2			1	30.00	40.00	2				2	
H5253	035	0	1	02	01	H5253_035_0	5	5	Group 5	11	3-1;3-2;3-3;3-4;8a1;8b1;8b2;9a1;9a2;9b;14d;14e2;14e3;14e4;14e5;16b;17b;	14b;	1	40	40	2			2				2	
H5253	035	0	1	02	01	H5253_035_0	5	6	Group 6	11	8a2;9d;	9d_2;14c4;14c7;16a;17b;	2			1	0.00	0.00	2				2	
H5253	035	0	1	02	01	H5253_035_0	5	7	Group 7	01	8b3;		2			1	30.00	30.00	2				2	
H5253	035	0	1	02	01	H5253_035_0	5	8	Group 8	01	10a1;10a2;		2			1	290.00	290.00	2				2	
H5253	035	0	1	02	01	H5253_035_0	5	9	Group 9	01	11b;11c;		1	50	50	2			2				2	
H5253	036	0	1	02	01	H5253_036_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	036	0	1	02	01	H5253_036_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	037	0	1	02	01	H5253_037_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	037	0	1	02	01	H5253_037_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	038	0	1	02	01	H5253_038_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	038	0	1	02	01	H5253_038_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	039	0	1	02	01	H5253_039_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	039	0	1	02	01	H5253_039_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	040	0	1	02	01	H5253_040_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	040	0	1	02	01	H5253_040_0	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	041	0	1	02	01	H5253_041_0	5	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H5253	042	0	1	02	01	H5253_042_0	5	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H5253	043	0	1	02	01	H5253_043_0	4	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;18a;	7f_2;9d_2;14b;17a;18a;	1	30	30	2			2				2	
H5253	043	0	1	02	01	H5253_043_0	4	2	Group 2	01	12;		1	20	20	2			2				2	
H5253	043	0	1	02	01	H5253_043_0	4	3	Group 3	11	7k;8a2;17b;	16a;16b;17b;18b;	2			1	0.00	0.00	2				2	
H5253	043	0	1	02	01	H5253_043_0	4	4	Group 4	01	14a;15;		1	0	30	2			2				2	
H5253	043	0	1	02	01	H5253_043_0	4	5	Group 5	01	10a1;10a2;		2			1	100.00	100.00	2				2	
H5253	043	0	1	02	01	H5253_043_0	4	6	Group 6	10		13b;14c8;	2			1	0.00	0.00	1	145.00	5		2	
H5253	043	0	1	02	01	H5253_043_0	4	7	Group 7	10		10b1;	1	75	75	2			2				2	
H5253	047	0	1	02	01	H5253_047_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	047	0	1	02	01	H5253_047_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	048	0	1	02	01	H5253_048_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	048	0	1	02	01	H5253_048_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	051	0	1	02	01	H5253_051_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	051	0	1	02	01	H5253_051_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	059	0	1	02	01	H5253_059_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H5253	060	0	1	02	01	H5253_060_0	4	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;18a;	7f_2;9d_2;14b;17a;	1	30	30	2			2				2	
H5253	060	0	1	02	01	H5253_060_0	4	2	Group 2	01	10a1;10a2;12;		1	20	20	2			2				2	
H5253	060	0	1	02	01	H5253_060_0	4	3	Group 3	11	7k;8a2;17b;	16a;16b;17b;	2			1	0.00	0.00	2				2	
H5253	060	0	1	02	01	H5253_060_0	4	4	Group 4	01	14a;15;		1	0	30	2			2				2	
H5253	060	0	1	02	01	H5253_060_0	4	5	Group 5	10		13b;14c8;	2			1	0.00	0.00	1	130.00	5		2	
H5253	060	0	1	02	01	H5253_060_0	4	6	Group 6	10		10b1;	1	75	75	2			2				2	
H5253	062	0	1	02	01	H5253_062_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	062	0	1	02	01	H5253_062_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	064	0	1	02	01	H5253_064_0	4	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;18a;	7f_2;9d_2;14b;17a;18a;	1	30	30	2			2				2	
H5253	064	0	1	02	01	H5253_064_0	4	2	Group 2	01	12;		1	20	20	2			2				2	
H5253	064	0	1	02	01	H5253_064_0	4	3	Group 3	11	7k;8a2;17b;	16a;16b;17b;18b;	2			1	0.00	0.00	2				2	
H5253	064	0	1	02	01	H5253_064_0	4	4	Group 4	01	14a;15;		1	0	30	2			2				2	
H5253	064	0	1	02	01	H5253_064_0	4	5	Group 5	01	10a1;10a2;		2			1	100.00	100.00	2				2	
H5253	064	0	1	02	01	H5253_064_0	4	6	Group 6	10		13b;14c8;	2			1	0.00	0.00	1	375.00	5		2	
H5253	064	0	1	02	01	H5253_064_0	4	7	Group 7	10		10b1;	1	75	75	2			2				2	
H5253	072	0	1	02	01	H5253_072_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	072	0	1	02	01	H5253_072_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	073	0	1	02	01	H5253_073_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	073	0	1	02	01	H5253_073_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	079	0	1	02	01	H5253_079_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	079	0	1	02	01	H5253_079_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	080	0	1	02	01	H5253_080_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	080	0	1	02	01	H5253_080_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	081	0	1	02	01	H5253_081_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	081	0	1	02	01	H5253_081_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	082	0	1	02	01	H5253_082_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	082	0	1	02	01	H5253_082_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	083	0	1	02	01	H5253_083_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	083	0	1	02	01	H5253_083_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	084	0	1	02	01	H5253_084_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	084	0	1	02	01	H5253_084_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	087	0	1	02	01	H5253_087_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	087	0	1	02	01	H5253_087_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	088	0	1	02	01	H5253_088_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	088	0	1	02	01	H5253_088_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	089	0	1	02	01	H5253_089_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	089	0	1	02	01	H5253_089_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	097	0	1	02	01	H5253_097_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	097	0	1	02	01	H5253_097_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	099	0	1	02	01	H5253_099_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	099	0	1	02	01	H5253_099_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	100	0	1	02	01	H5253_100_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	100	0	1	02	01	H5253_100_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	102	0	1	02	01	H5253_102_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	102	0	1	02	01	H5253_102_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	103	0	1	02	01	H5253_103_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	103	0	1	02	01	H5253_103_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	104	0	1	02	01	H5253_104_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	104	0	1	02	01	H5253_104_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	105	0	1	02	01	H5253_105_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	107	1	1	02	01	H5253_107_1	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	107	1	1	02	01	H5253_107_1	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	107	2	1	02	01	H5253_107_2	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	107	2	1	02	01	H5253_107_2	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	108	1	1	02	01	H5253_108_1	6	1	Group 1	10		16b;	1	0	50	2			2				2	
H5253	108	1	1	02	01	H5253_108_1	6	2	Group 2	10		16a;	2			1	0.00	0.00	2				2	
H5253	108	2	1	02	01	H5253_108_2	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	108	2	1	02	01	H5253_108_2	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	108	3	1	02	01	H5253_108_3	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	108	3	1	02	01	H5253_108_3	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	109	1	1	02	01	H5253_109_1	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	109	1	1	02	01	H5253_109_1	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	109	2	1	02	01	H5253_109_2	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	109	2	1	02	01	H5253_109_2	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	109	4	1	02	01	H5253_109_4	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	109	4	1	02	01	H5253_109_4	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	110	0	1	02	01	H5253_110_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	111	1	1	02	01	H5253_111_1	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	111	1	1	02	01	H5253_111_1	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	111	2	1	02	01	H5253_111_2	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	111	2	1	02	01	H5253_111_2	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	112	1	1	02	01	H5253_112_1	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	112	1	1	02	01	H5253_112_1	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	112	2	1	02	01	H5253_112_2	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	112	2	1	02	01	H5253_112_2	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	113	0	1	02	01	H5253_113_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	113	0	1	02	01	H5253_113_0	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	116	0	1	02	01	H5253_116_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	116	0	1	02	01	H5253_116_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	117	0	1	02	01	H5253_117_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	117	0	1	02	01	H5253_117_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	119	0	1	02	01	H5253_119_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	119	0	1	02	01	H5253_119_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	120	0	1	02	01	H5253_120_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	120	0	1	02	01	H5253_120_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	121	0	1	02	01	H5253_121_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	122	0	1	02	01	H5253_122_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	122	0	1	02	01	H5253_122_0	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	124	1	1	02	01	H5253_124_1	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	124	1	1	02	01	H5253_124_1	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	124	2	1	02	01	H5253_124_2	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	124	2	1	02	01	H5253_124_2	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	125	1	1	02	01	H5253_125_1	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	125	1	1	02	01	H5253_125_1	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	125	2	1	02	01	H5253_125_2	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	125	2	1	02	01	H5253_125_2	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	126	1	1	02	01	H5253_126_1	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	126	1	1	02	01	H5253_126_1	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	126	2	1	02	01	H5253_126_2	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	126	2	1	02	01	H5253_126_2	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	127	0	1	02	01	H5253_127_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	128	0	1	02	01	H5253_128_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	128	0	1	02	01	H5253_128_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	130	0	1	02	01	H5253_130_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	130	0	1	02	01	H5253_130_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	131	0	1	02	01	H5253_131_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	131	0	1	02	01	H5253_131_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	132	0	1	02	01	H5253_132_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	132	0	1	02	01	H5253_132_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	133	0	1	02	01	H5253_133_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	133	0	1	02	01	H5253_133_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	134	0	1	02	01	H5253_134_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	134	0	1	02	01	H5253_134_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	135	0	1	02	01	H5253_135_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	136	0	1	02	01	H5253_136_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	136	0	1	02	01	H5253_136_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	141	0	1	02	01	H5253_141_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	141	0	1	02	01	H5253_141_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	142	0	1	02	01	H5253_142_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	142	0	1	02	01	H5253_142_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	143	0	1	02	01	H5253_143_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	143	0	1	02	01	H5253_143_0	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	144	1	1	02	01	H5253_144_1	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	144	1	1	02	01	H5253_144_1	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5253	144	2	1	02	01	H5253_144_2	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5253	144	2	1	02	01	H5253_144_2	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5296	003	0	1	02	01	H5296_003_0	13	1	$10	01	7d;		2			2			2				2	
H5296	004	0	1	02	01	H5296_004_0	13	1	$0	01	7d;		2			2			2				2	
H5296	005	0	1	02	01	H5296_005_0	13	1	$0 copay	01	7d;		2			2			2				2	
H5322	001	0	1	02	01	H5322_001_0	4	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;18a;	7f_2;9d_2;14b;17a;	1	30	30	2			2				2	
H5322	001	0	1	02	01	H5322_001_0	4	2	Group 2	01	10a1;10a2;12;		1	20	20	2			2				2	
H5322	001	0	1	02	01	H5322_001_0	4	3	Group 3	11	7k;8a2;17b;	17b;	2			1	0.00	0.00	2				2	
H5322	001	0	1	02	01	H5322_001_0	4	4	Group 4	01	14a;15;		1	0	30	2			2				2	
H5322	001	0	1	02	01	H5322_001_0	4	5	Group 5	10		10b1;	1	75	75	2			2				2	
H5322	001	0	1	02	01	H5322_001_0	4	6	Group 6	10		13b;14c8;	2			1	0.00	0.00	1	100.00	5		2	
H5322	003	0	1	02	01	H5322_003_0	5	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H5322	025	0	1	02	01	H5322_025_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H5322	026	0	1	02	01	H5322_026_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5322	026	0	1	02	01	H5322_026_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H5322	028	0	1	02	01	H5322_028_0	4	1	Group 1	01	5;7e;7h;9c;		1	40	40	2			2				2	
H5322	028	0	1	02	01	H5322_028_0	4	2	Group 2	01	10a1;10a2;		1	20	20	2			2				2	
H5322	028	0	1	02	01	H5322_028_0	4	3	Group 3	10		16a;16b;	2			1	0.00	0.00	2				2	
H5322	029	0	1	02	01	H5322_029_0	4	1	Group 1	01	5;7e;7h;9c;		1	40	40	2			2				2	
H5322	029	0	1	02	01	H5322_029_0	4	2	Group 2	01	10a1;10a2;		1	20	20	2			2				2	
H5322	029	0	1	02	01	H5322_029_0	4	3	Group 3	10		16a;16b;	2			1	0.00	0.00	2				2	
H5322	030	0	1	02	01	H5322_030_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H5322	030	0	1	02	01	H5322_030_0	4	2	Group 2	01	5;7e;7h;9c;		1	40	40	2			2				2	
H5322	030	0	1	02	01	H5322_030_0	4	3	Group 3	01	10a1;10a2;		1	20	20	2			2				2	
H5322	031	0	1	02	01	H5322_031_0	5	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H5322	033	0	1	02	01	H5322_033_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5322	033	0	1	02	01	H5322_033_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5322	034	0	1	02	01	H5322_034_0	4	1	Group 1	01	5;7e;7h;9c;		1	40	40	2			2				2	
H5322	034	0	1	02	01	H5322_034_0	4	2	Group 2	01	10a1;10a2;		2			1	290.00	290.00	2				2	
H5322	034	0	1	02	01	H5322_034_0	4	3	Group 3	10		16a;	2			1	0.00	0.00	2				2	
H5322	034	0	1	02	01	H5322_034_0	4	4	Group 4	10		16b;	1	0	50	2			2				2	
H5322	038	0	1	02	01	H5322_038_0	4	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5322	038	0	1	02	01	H5322_038_0	4	2	Group 2	10		16b;	1	0	50	2			2				2	
H5322	039	0	1	02	01	H5322_039_0	5	1	Group 1	01	5;7e;7h;9c;		1	40	40	2			2				2	
H5322	039	0	1	02	01	H5322_039_0	5	2	Group 2	01	10a1;10a2;		2			1	275.00	275.00	2				2	
H5322	039	0	1	02	01	H5322_039_0	5	3	Group 3	10		16a;	2			1	0.00	0.00	2				2	
H5322	039	0	1	02	01	H5322_039_0	5	4	Group 4	10		16b;	1	0	50	2			2				2	
H5322	040	0	1	02	01	H5322_040_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5322	040	0	1	02	01	H5322_040_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5322	041	0	1	02	01	H5322_041_0	5	1	Group 1	01	5;7e;7h;9c;		1	40	40	2			2				2	
H5322	041	0	1	02	01	H5322_041_0	5	2	Group 2	01	10a1;10a2;		2			1	290.00	290.00	2				2	
H5322	041	0	1	02	01	H5322_041_0	5	3	Group 3	10		16a;	2			1	0.00	0.00	2				2	
H5322	041	0	1	02	01	H5322_041_0	5	4	Group 4	10		16b;	1	0	50	2			2				2	
H5322	042	0	1	02	01	H5322_042_0	6	1	Group 1	01	5;7e;7h;9c;		1	40	40	2			2				2	
H5322	042	0	1	02	01	H5322_042_0	6	2	Group 2	01	10a1;10a2;		2			1	290.00	290.00	2				2	
H5322	042	0	1	02	01	H5322_042_0	6	3	Group 3	10		16a;	2			1	0.00	0.00	2				2	
H5322	042	0	1	02	01	H5322_042_0	6	4	Group 4	10		16b;	1	0	50	2			2				2	
H5322	043	0	1	02	01	H5322_043_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5322	043	0	1	02	01	H5322_043_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H5322	044	0	1	02	01	H5322_044_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H5322	044	0	1	02	01	H5322_044_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H5373	001	0	1	02	01	H5373_001_0	10	1	Dental-2500	11	16b;	16b;	1	30	30	2			2				2	
H5373	001	0	1	02	01	H5373_001_0	10	2	Non Medicare Eye Exam	10		17a;	2			1	30.00	30.00	2				2	
H5373	001	0	1	02	01	H5373_001_0	10	3	Non Medicare Eye Wear OON	10		17b;	2			1	100.00	100.00	2				2	
H5373	001	0	1	02	01	H5373_001_0	10	4	Prev Dental OON	10		16a;	1	30	30	2			2				2	
H5373	001	0	1	02	01	H5373_001_0	10	5	Comp Dental Medicare				1	30	30	2			2				2	
H5373	001	0	1	02	01	H5373_001_0	10	6	Eyewear OON Medicare	01	17b;		2			1	25.00	100.00	2				2	
H5373	001	0	1	02	01	H5373_001_0	10	7	Medicare Eye Exam	01	17a;		2			1	30.00	30.00	2				2	
H5377	002	0	1	02	01	H5377_002_0	11	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	1500.00	3		2	
H5427	112	0	1	02	01	H5427_112_0	6	1	OTC	10		13b;	2			1	0.00	0.00	1	50.00	7		2	
H5427	112	0	1	02	01	H5427_112_0	6	10	20% Group	01	8b2;10a2;11a;11b;12;		1	20	20	2			2				2	
H5427	112	0	1	02	01	H5427_112_0	6	11	Outpatient Xray	01	8b3;		2			1	0.00	195.00	2				2	
H5427	112	0	1	02	01	H5427_112_0	6	12	$195 Outpatient Hospital /Observation	01	9a1;9a2;		2			1	195.00	195.00	2				2	
H5427	112	0	1	02	01	H5427_112_0	6	13	ASC	01	9b;		2			1	25.00	25.00	2				2	
H5427	112	0	1	02	01	H5427_112_0	6	14	Outpatient Substance Abuse	01	9c;		2			1	10.00	195.00	2				2	
H5427	112	0	1	02	01	H5427_112_0	6	15	Ground Ambulance $175	01	10a1;		2			1	175.00	175.00	2				2	
H5427	112	0	1	02	01	H5427_112_0	6	16	Diabetic Supplies/Therapeutic Shoes	01	11c;		1	20	20	1	0.00	0.00	2				2	
H5427	112	0	1	02	01	H5427_112_0	6	17	Part B Drugs/Insulins/Chemo Rad	01	15;		1	0	20	1	35.00	35.00	2				2	
H5427	112	0	1	02	01	H5427_112_0	6	2	$10 Group	01	3-1;3-2;3-3;3-4;7b;7c;7d;7e;7f;7h;7i;		2			1	10.00	10.00	2				2	
H5427	112	0	1	02	01	H5427_112_0	6	3	$55 Partial Hospitalization	01	5;		2			1	55.00	55.00	2				2	
H5427	112	0	1	02	01	H5427_112_0	6	4	$0 Group	01	6;7a;9d;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		2			1	0.00	0.00	2				2	
H5427	112	0	1	02	01	H5427_112_0	6	5	$0-$10 Group	01	7g;		2			1	0.00	10.00	2				2	
H5427	112	0	1	02	01	H5427_112_0	6	6	20% / $0-$195	01	7k;		1	20	20	1	0.00	195.00	2				2	
H5427	112	0	1	02	01	H5427_112_0	6	7	Diagnostic Procedures/Tests	01	8a1;		1	20	20	1	0.00	195.00	2				2	
H5427	112	0	1	02	01	H5427_112_0	6	8	Lab Services $0-$50	01	8a2;		2			1	0.00	50.00	2				2	
H5427	112	0	1	02	01	H5427_112_0	6	9	Diagnostic Radiological $25-$195	01	8b1;		2			1	25.00	195.00	2				2	
H5427	113	0	1	02	01	H5427_113_0	6	1	$55 Partial Hospitalization	01	5;		2			1	55.00	55.00	2				2	
H5427	113	0	1	02	01	H5427_113_0	6	10	$0-$95 Group	01	8b3;		2			1	0.00	95.00	2				2	
H5427	113	0	1	02	01	H5427_113_0	6	11	$95 Group	01	9a1;9a2;		2			1	95.00	95.00	2				2	
H5427	113	0	1	02	01	H5427_113_0	6	12	$25 Group	01	9b;		2			1	25.00	25.00	2				2	
H5427	113	0	1	02	01	H5427_113_0	6	13	$10-$95 Group 9C	01	9c;		2			1	10.00	95.00	2				2	
H5427	113	0	1	02	01	H5427_113_0	6	14	$175 Ground Ambulance Group	01	10a1;		2			1	175.00	175.00	2				2	
H5427	113	0	1	02	01	H5427_113_0	6	15	0%-20% Diabetic Supplies/Therap Shoes	01	11c;		1	0	20	2			2				2	
H5427	113	0	1	02	01	H5427_113_0	6	16	OTC	10		13b;	2			1	0.00	0.00	1	50.00	7		2	
H5427	113	0	1	02	01	H5427_113_0	6	17	Part B Insulins/Chemo Rad/Other	01	15;		1	0	20	1	35.00	35.00	2				2	
H5427	113	0	1	02	01	H5427_113_0	6	2	$10 Group	01	3-1;3-2;3-3;3-4;7b;7c;7d;7e;7f;7h;7i;		2			1	10.00	10.00	2				2	
H5427	113	0	1	02	01	H5427_113_0	6	3	$0 Group	01	6;7a;9d;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		2			1	0.00	0.00	2				2	
H5427	113	0	1	02	01	H5427_113_0	6	4	7G - $0-$10 Group	01	7g;		2			1	0.00	10.00	2				2	
H5427	113	0	1	02	01	H5427_113_0	6	5	7k Opioid 20%/$0-$95 Group	01	7k;		1	20	20	1	0.00	95.00	2				2	
H5427	113	0	1	02	01	H5427_113_0	6	6	8A1 20%/$0-$95	01	8a1;		1	20	20	1	0.00	95.00	2				2	
H5427	113	0	1	02	01	H5427_113_0	6	7	$0-$50 Labs	01	8a2;		2			1	0.00	50.00	2				2	
H5427	113	0	1	02	01	H5427_113_0	6	8	8b1 Group	01	8b1;		2			1	25.00	95.00	2				2	
H5427	113	0	1	02	01	H5427_113_0	6	9	20% Group	01	8b2;10a2;11a;11b;12;		1	20	20	2			2				2	
H5472	001	0	1	02	01	H5472_001_0	15	1	Physician Specialist	01	7d;		2			1	15.00	15.00	2				2	
H5472	002	0	1	02	01	H5472_002_0	14	1	Physician Specialist	01	7d;		2			1	15.00	15.00	2				2	
H5472	003	0	1	02	01	H5472_003_0	12	1																
H5472	004	0	1	02	01	H5472_004_0	16	1	$0 copay	01	7d;		2			2			2				2	
H5475	001	0	1	02	01	H5475_001_0	16	1	20%	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	20	20	2			2				2	
H5475	001	0	1	02	01	H5475_001_0	16	2	Insulin & Part B Drugs	01	15;		1	0	20	1	35.00	35.00	2				2	
H5475	011	0	1	02	01	H5475_011_0	16	1	40%	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	40	40	2			2				2	
H5475	011	0	1	02	01	H5475_011_0	16	2	Insulin/Part B Drugs and Dialysis	01	12;15;		1	0	20	1	35.00	35.00	2				2	
H5475	021	0	1	02	01	H5475_021_0	15	1	20%	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	20	20	2			2				2	
H5475	021	0	1	02	01	H5475_021_0	15	2	Insulin & Part B Drugs	01	15;		1	0	20	1	35.00	35.00	2				2	
H5475	022	0	1	02	01	H5475_022_0	16	1	30%	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	30	30	2			2				2	
H5475	022	0	1	02	01	H5475_022_0	16	2	Part B Drugs and Dialysis	01	12;15;		1	0	20	1	35.00	35.00	2				2	
H5475	024	0	1	02	01	H5475_024_0	6	1	40%	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	40	40	2			2				2	
H5475	024	0	1	02	01	H5475_024_0	6	2	Insulin/Part B Drugs and Dialysis	01	12;15;		1	0	20	1	35.00	35.00	2				2	
H5475	026	0	1	02	01	H5475_026_0	16	1	30%	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	30	30	2			2				2	
H5475	026	0	1	02	01	H5475_026_0	16	2	Insulin/Part B drugs and Dialysis	01	12;15;		1	0	20	1	35.00	35.00	2				2	
H5577	008	0	1	02	01	H5577_008_0	5	1	35% Coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;15;16b;17a;17b;18a;	7b;9d_2;16a;16b;17a;17b;18a;	1	35	35	2			2				2	
H5577	008	0	1	02	01	H5577_008_0	5	2	0% Coinsurance	11	9a2;14a;14e2;14e3;14e4;14e5;	18a2;18b;	2			2			2				2	
H5591	005	0	1	02	01	H5591_005_0	6	1	1	01	11c;12;15;17b;		1	20	20	2			2				2	
H5591	005	0	1	02	01	H5591_005_0	6	10	10	01	8b3;		1	15	15	2			2				2	
H5591	005	0	1	02	01	H5591_005_0	6	11	11	01	7a;		2			1	35.00	35.00	2				2	
H5591	005	0	1	02	01	H5591_005_0	6	12	12	01	7e;7h;9c;		2			1	30.00	30.00	2				2	
H5591	005	0	1	02	01	H5591_005_0	6	13	OON Observation	01	9a2;		2			1	275.00	275.00	2				2	
H5591	005	0	1	02	01	H5591_005_0	6	14	OON Podiatry	01	7f;		2			1	35.00	55.00	2				2	
H5591	005	0	1	02	01	H5591_005_0	6	2	2	01	8b1;8b2;11a;11b;		1	30	30	2			2				2	
H5591	005	0	1	02	01	H5591_005_0	6	3	3	01	7b;7c;7d;7g;7i;16b;17a;18a;		2			1	55.00	55.00	2				2	
H5591	005	0	1	02	01	H5591_005_0	6	4	4	01	9b;		2			1	200.00	200.00	2				2	
H5591	005	0	1	02	01	H5591_005_0	6	5	5	01	9a1;		2			1	400.00	400.00	2				2	
H5591	005	0	1	02	01	H5591_005_0	6	6	6	01	10a1;10a2;		2			1	325.00	325.00	2				2	
H5591	005	0	1	02	01	H5591_005_0	6	7	7	01	8a1;		1	0	15	2			2				2	
H5591	005	0	1	02	01	H5591_005_0	6	8	8	01	8a2;		1	0	20	1	0.00	5.00	2				2	
H5591	005	0	1	02	01	H5591_005_0	6	9	9	01	9d;14d;14e1;14e2;		2			2			2				2	
H5591	006	1	1	02	01	H5591_006_1	6	1	1	01	11c;12;15;17b;		1	20	20	2			2				2	
H5591	006	1	1	02	01	H5591_006_1	6	10	10	01	8b3;		1	15	15	2			2				2	
H5591	006	1	1	02	01	H5591_006_1	6	11	11	01	7a;		2			1	35.00	35.00	2				2	
H5591	006	1	1	02	01	H5591_006_1	6	12	12	01	7e;7h;9c;		2			1	30.00	30.00	2				2	
H5591	006	1	1	02	01	H5591_006_1	6	13	OON Observation	01	9a2;		2			1	275.00	275.00	2				2	
H5591	006	1	1	02	01	H5591_006_1	6	14	OON Podiatry	01	7f;		2			1	35.00	55.00	2				2	
H5591	006	1	1	02	01	H5591_006_1	6	2	2	01	8b1;8b2;11a;11b;		1	30	30	2			2				2	
H5591	006	1	1	02	01	H5591_006_1	6	3	3	01	7b;7c;7d;7g;7i;16b;17a;18a;		2			1	55.00	55.00	2				2	
H5591	006	1	1	02	01	H5591_006_1	6	4	4	01	9b;		2			1	200.00	200.00	2				2	
H5591	006	1	1	02	01	H5591_006_1	6	5	5	01	9a1;		2			1	400.00	400.00	2				2	
H5591	006	1	1	02	01	H5591_006_1	6	6	6	01	10a1;10a2;		2			1	325.00	325.00	2				2	
H5591	006	1	1	02	01	H5591_006_1	6	7	7	01	8a1;		1	0	15	2			2				2	
H5591	006	1	1	02	01	H5591_006_1	6	8	8	01	8a2;		1	0	20	1	0.00	5.00	2				2	
H5591	006	1	1	02	01	H5591_006_1	6	9	9	01	9d;14d;14e1;14e2;		2			2			2				2	
H5591	006	2	1	02	01	H5591_006_2	6	1	1	01	11c;12;15;17b;		1	20	20	2			2				2	
H5591	006	2	1	02	01	H5591_006_2	6	10	10	01	8b3;		1	15	15	2			2				2	
H5591	006	2	1	02	01	H5591_006_2	6	11	11	01	7a;		2			1	35.00	35.00	2				2	
H5591	006	2	1	02	01	H5591_006_2	6	12	12	01	7e;7h;9c;		2			1	30.00	30.00	2				2	
H5591	006	2	1	02	01	H5591_006_2	6	13	OON Observation	01	9a2;		2			1	275.00	275.00	2				2	
H5591	006	2	1	02	01	H5591_006_2	6	14	OON Podiatry	01	7f;		2			1	35.00	55.00	2				2	
H5591	006	2	1	02	01	H5591_006_2	6	2	2	01	8b1;8b2;11a;11b;		1	30	30	2			2				2	
H5591	006	2	1	02	01	H5591_006_2	6	3	3	01	7b;7c;7d;7g;7i;16b;17a;18a;		2			1	55.00	55.00	2				2	
H5591	006	2	1	02	01	H5591_006_2	6	4	4	01	9b;		2			1	200.00	200.00	2				2	
H5591	006	2	1	02	01	H5591_006_2	6	5	5	01	9a1;		2			1	400.00	400.00	2				2	
H5591	006	2	1	02	01	H5591_006_2	6	6	6	01	10a1;10a2;		2			1	325.00	325.00	2				2	
H5591	006	2	1	02	01	H5591_006_2	6	7	7	01	8a1;		1	0	15	2			2				2	
H5591	006	2	1	02	01	H5591_006_2	6	8	8	01	8a2;		1	0	20	1	0.00	5.00	2				2	
H5591	006	2	1	02	01	H5591_006_2	6	9	9	01	9d;14d;14e1;14e2;		2			2			2				2	
H5591	006	4	1	02	01	H5591_006_4	6	1	1	01	11c;12;15;17b;		1	20	20	2			2				2	
H5591	006	4	1	02	01	H5591_006_4	6	10	10	01	8b3;		1	15	15	2			2				2	
H5591	006	4	1	02	01	H5591_006_4	6	11	11	01	7a;		2			1	35.00	35.00	2				2	
H5591	006	4	1	02	01	H5591_006_4	6	12	12	01	7e;7h;9c;		2			1	30.00	30.00	2				2	
H5591	006	4	1	02	01	H5591_006_4	6	13	OON Observation	01	9a2;		2			1	275.00	275.00	2				2	
H5591	006	4	1	02	01	H5591_006_4	6	14	OON Podiatry	01	7f;		2			1	35.00	55.00	2				2	
H5591	006	4	1	02	01	H5591_006_4	6	2	2	01	8b1;8b2;11a;11b;		1	30	30	2			2				2	
H5591	006	4	1	02	01	H5591_006_4	6	3	3	01	7b;7c;7d;7g;7i;16b;17a;18a;		2			1	55.00	55.00	2				2	
H5591	006	4	1	02	01	H5591_006_4	6	4	4	01	9b;		2			1	200.00	200.00	2				2	
H5591	006	4	1	02	01	H5591_006_4	6	5	5	01	9a1;		2			1	400.00	400.00	2				2	
H5591	006	4	1	02	01	H5591_006_4	6	6	6	01	10a1;10a2;		2			1	325.00	325.00	2				2	
H5591	006	4	1	02	01	H5591_006_4	6	7	7	01	8a1;		1	0	15	2			2				2	
H5591	006	4	1	02	01	H5591_006_4	6	8	8	01	8a2;		1	0	20	1	0.00	5.00	2				2	
H5591	006	4	1	02	01	H5591_006_4	6	9	9	01	9d;14d;14e1;14e2;		2			2			2				2	
H5591	006	5	1	02	01	H5591_006_5	6	1	1	01	11c;12;15;17b;		1	20	20	2			2				2	
H5591	006	5	1	02	01	H5591_006_5	6	10	10	01	8b3;		1	15	15	2			2				2	
H5591	006	5	1	02	01	H5591_006_5	6	11	11	01	7a;		2			1	35.00	35.00	2				2	
H5591	006	5	1	02	01	H5591_006_5	6	12	12	01	7e;7h;9c;		2			1	30.00	30.00	2				2	
H5591	006	5	1	02	01	H5591_006_5	6	13	OON Observation	01	9a2;		2			1	275.00	275.00	2				2	
H5591	006	5	1	02	01	H5591_006_5	6	14	OON Podiatry	01	7f;		2			1	35.00	55.00	2				2	
H5591	006	5	1	02	01	H5591_006_5	6	2	2	01	8b1;8b2;11a;11b;		1	30	30	2			2				2	
H5591	006	5	1	02	01	H5591_006_5	6	3	3	01	7b;7c;7d;7g;7i;16b;17a;18a;		2			1	55.00	55.00	2				2	
H5591	006	5	1	02	01	H5591_006_5	6	4	4	01	9b;		2			1	200.00	200.00	2				2	
H5591	006	5	1	02	01	H5591_006_5	6	5	5	01	9a1;		2			1	400.00	400.00	2				2	
H5591	006	5	1	02	01	H5591_006_5	6	6	6	01	10a1;10a2;		2			1	325.00	325.00	2				2	
H5591	006	5	1	02	01	H5591_006_5	6	7	7	01	8a1;		1	0	15	2			2				2	
H5591	006	5	1	02	01	H5591_006_5	6	8	8	01	8a2;		1	0	20	1	0.00	5.00	2				2	
H5591	006	5	1	02	01	H5591_006_5	6	9	9	01	9d;14d;14e1;14e2;		2			2			2				2	
H5591	009	0	1	02	01	H5591_009_0	6	1	1	01	11c;12;15;17b;		1	20	20	2			2				2	
H5591	009	0	1	02	01	H5591_009_0	6	10	10	01	8b3;		1	15	15	2			2				2	
H5591	009	0	1	02	01	H5591_009_0	6	11	11	01	7a;		2			1	35.00	35.00	2				2	
H5591	009	0	1	02	01	H5591_009_0	6	12	12	01	7e;7h;9c;		2			1	30.00	30.00	2				2	
H5591	009	0	1	02	01	H5591_009_0	6	13	OON Podiatry	01	7f;		2			1	35.00	55.00	2				2	
H5591	009	0	1	02	01	H5591_009_0	6	14	OON Observation	01	9a2;		2			1	345.00	345.00	2				2	
H5591	009	0	1	02	01	H5591_009_0	6	2	2	01	8b1;8b2;11a;11b;		1	30	30	2			2				2	
H5591	009	0	1	02	01	H5591_009_0	6	3	3	01	7b;7c;7d;7g;7i;16b;17a;18a;		2			1	55.00	55.00	2				2	
H5591	009	0	1	02	01	H5591_009_0	6	4	4	01	9b;		2			1	200.00	200.00	2				2	
H5591	009	0	1	02	01	H5591_009_0	6	5	5	01	9a1;		2			1	400.00	400.00	2				2	
H5591	009	0	1	02	01	H5591_009_0	6	6	6	01	10a1;10a2;		2			1	325.00	325.00	2				2	
H5591	009	0	1	02	01	H5591_009_0	6	7	7	01	8a1;		1	0	15	2			2				2	
H5591	009	0	1	02	01	H5591_009_0	6	8	8	01	8a2;		1	0	20	1	0.00	5.00	2				2	
H5591	009	0	1	02	01	H5591_009_0	6	9	9	01	9d;14d;14e1;14e2;		2			2			2				2	
H5591	013	0	1	02	01	H5591_013_0	6	1	1	01	11c;12;15;17b;		1	20	20	2			2				2	
H5591	013	0	1	02	01	H5591_013_0	6	10	10	01	8b3;		1	15	15	2			2				2	
H5591	013	0	1	02	01	H5591_013_0	6	11	11	01	7a;		2			1	35.00	35.00	2				2	
H5591	013	0	1	02	01	H5591_013_0	6	12	12	01	7e;7h;9c;		2			1	30.00	30.00	2				2	
H5591	013	0	1	02	01	H5591_013_0	6	13	OON Observation	01	9a2;		2			1	345.00	345.00	2				2	
H5591	013	0	1	02	01	H5591_013_0	6	14	OON Podiatry	01	7f;		2			1	35.00	55.00	2				2	
H5591	013	0	1	02	01	H5591_013_0	6	2	2	01	8b1;8b2;11a;11b;		1	30	30	2			2				2	
H5591	013	0	1	02	01	H5591_013_0	6	3	3	01	7b;7c;7d;7g;7i;16b;17a;18a;		2			1	55.00	55.00	2				2	
H5591	013	0	1	02	01	H5591_013_0	6	4	4	01	9b;		2			1	200.00	200.00	2				2	
H5591	013	0	1	02	01	H5591_013_0	6	5	5	01	9a1;		2			1	400.00	400.00	2				2	
H5591	013	0	1	02	01	H5591_013_0	6	6	6	01	10a1;10a2;		2			1	325.00	325.00	2				2	
H5591	013	0	1	02	01	H5591_013_0	6	7	7	01	8a1;		1	0	15	2			2				2	
H5591	013	0	1	02	01	H5591_013_0	6	8	8	01	8a2;		1	0	20	1	0.00	5.00	2				2	
H5591	013	0	1	02	01	H5591_013_0	6	9	9	01	9d;14d;14e1;14e2;		2			2			2				2	
H5591	015	1	1	02	01	H5591_015_1	6	1	1	01	11c;12;15;17b;		1	20	20	2			2				2	
H5591	015	1	1	02	01	H5591_015_1	6	10	10	01	8b3;		1	15	15	2			2				2	
H5591	015	1	1	02	01	H5591_015_1	6	11	11	01	7a;		2			1	35.00	35.00	2				2	
H5591	015	1	1	02	01	H5591_015_1	6	12	12	01	7e;7h;9c;		2			1	30.00	30.00	2				2	
H5591	015	1	1	02	01	H5591_015_1	6	13	OON Observation	01	9a2;		2			1	325.00	325.00	2				2	
H5591	015	1	1	02	01	H5591_015_1	6	14	OON Podiatry	01	7f;		2			1	35.00	55.00	2				2	
H5591	015	1	1	02	01	H5591_015_1	6	2	2	01	8b1;8b2;11a;11b;		1	30	30	2			2				2	
H5591	015	1	1	02	01	H5591_015_1	6	3	3	01	7b;7c;7d;7g;7i;16b;17a;18a;		2			1	55.00	55.00	2				2	
H5591	015	1	1	02	01	H5591_015_1	6	4	4	01	9b;		2			1	200.00	200.00	2				2	
H5591	015	1	1	02	01	H5591_015_1	6	5	5	01	9a1;		2			1	400.00	400.00	2				2	
H5591	015	1	1	02	01	H5591_015_1	6	6	6	01	10a1;10a2;		2			1	325.00	325.00	2				2	
H5591	015	1	1	02	01	H5591_015_1	6	7	7	01	8a1;		1	0	15	2			2				2	
H5591	015	1	1	02	01	H5591_015_1	6	8	8	01	8a2;		1	0	20	1	0.00	5.00	2				2	
H5591	015	1	1	02	01	H5591_015_1	6	9	9	01	9d;14d;14e1;14e2;		2			2			2				2	
H5591	015	2	1	02	01	H5591_015_2	6	1	1	01	11c;12;15;17b;		1	20	20	2			2				2	
H5591	015	2	1	02	01	H5591_015_2	6	10	10	01	8b3;		1	15	15	2			2				2	
H5591	015	2	1	02	01	H5591_015_2	6	11	11	01	7a;		2			1	35.00	35.00	2				2	
H5591	015	2	1	02	01	H5591_015_2	6	12	12	01	7e;7h;9c;		2			1	30.00	30.00	2				2	
H5591	015	2	1	02	01	H5591_015_2	6	13	OON Observation	01	9a2;		2			1	275.00	275.00	2				2	
H5591	015	2	1	02	01	H5591_015_2	6	14	OON Podiatry	01	7f;		2			1	35.00	55.00	2				2	
H5591	015	2	1	02	01	H5591_015_2	6	2	2	01	8b1;8b2;11a;11b;		1	30	30	2			2				2	
H5591	015	2	1	02	01	H5591_015_2	6	3	3	01	7b;7c;7d;7g;7i;16b;17a;18a;		2			1	55.00	55.00	2				2	
H5591	015	2	1	02	01	H5591_015_2	6	4	4	01	9b;		2			1	200.00	200.00	2				2	
H5591	015	2	1	02	01	H5591_015_2	6	5	5	01	9a1;		2			1	400.00	400.00	2				2	
H5591	015	2	1	02	01	H5591_015_2	6	6	6	01	10a1;10a2;		2			1	325.00	325.00	2				2	
H5591	015	2	1	02	01	H5591_015_2	6	7	7	01	8a1;		1	0	15	2			2				2	
H5591	015	2	1	02	01	H5591_015_2	6	8	8	01	8a2;		1	0	20	1	0.00	5.00	2				2	
H5591	015	2	1	02	01	H5591_015_2	6	9	9	01	9d;14d;14e1;14e2;		2			2			2				2	
H5591	801	0	1	02	01	H5591_801_0	3	1	1	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9b;9c;9d;11a;11b;11c;12;14a;14d;15;16b;17a;17b;18a;		1	30	30	2			2				2	
H5591	802	0	1	02	01	H5591_802_0	3	1	1	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9b;9c;9d;11a;11b;11c;12;14a;14d;15;16b;17a;17b;18a;		1	30	30	2			2				2	
H5599	002	0	1	02	01	H5599_002_0	6	1	50%	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	50	50	2			2				2	
H5599	002	0	1	02	01	H5599_002_0	6	2	Insulin/Part B Drugs and Dialysis	01	12;15;		1	0	20	1	35.00	35.00	2				2	
H5619	049	0	1	02	01	H5619_049_0	5	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	2500.00	3		2	
H5619	051	0	1	02	01	H5619_051_0	5	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	2500.00	3		2	
H5619	053	0	1	02	01	H5619_053_0	5	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	1000.00	3		2	
H5619	053	0	1	02	01	H5619_053_0	5	2	Point-of-Service Group 2	10		9d_2;	2			2			2				2	
H5619	054	0	1	02	01	H5619_054_0	5	1	Point-of-Service Group 2	10		16a;16b;	2			1	0.00	0.00	2				2	
H5619	054	0	1	02	01	H5619_054_0	5	2	Point-of-Service Group 1	10		9d_2;	2			2			2				2	
H5619	069	0	1	02	01	H5619_069_0	6	1	Point of Service Group 1	10		9d_2;13b;13c;14c4;	2			1	0.00	0.00	2				2	
H5619	069	0	1	02	01	H5619_069_0	6	2	Point of Service Group 2	10		16a;16b;	2			1	0.00	0.00	1	1000.00	3		2	
H5619	111	0	1	02	01	H5619_111_0	5	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	1500.00	3		2	
H5619	113	0	1	02	01	H5619_113_0	5	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	1500.00	3		2	
H5619	123	0	1	02	01	H5619_123_0	5	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	3000.00	3		2	
H5619	126	0	1	02	01	H5619_126_0	7	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	5000.00	3		2	
H5619	156	0	1	02	01	H5619_156_0	5	1	Point-of-Service Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H5619	158	0	1	02	01	H5619_158_0	5	1	Point-of-Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	2000.00	3		2	
H5619	162	0	1	02	01	H5619_162_0	5	1	Point-of-Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	3000.00	3		2	
H5652	001	0	1	02	01	H5652_001_0	5	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7e;7h;8a1;8b1;8b2;9a1;9a2;9b;9c;9d;11a;11b;11c;14d;14e2;14e3;14e4;14e5;16b;	9d_2;14b;	1	30	30	2			2				2	
H5652	001	0	1	02	01	H5652_001_0	5	10	Group 10	10		16b;	1	0	50	2			2				2	
H5652	001	0	1	02	01	H5652_001_0	5	11	Group 11	10		13b;14c8;	2			1	0.00	0.00	1	60.00	5		2	
H5652	001	0	1	02	01	H5652_001_0	5	2	Group 2	01	14a;15;		1	0	30	2			2				2	
H5652	001	0	1	02	01	H5652_001_0	5	3	Group 3	11	7a;7k;8a2;	16a;17b;	2			1	0.00	0.00	2				2	
H5652	001	0	1	02	01	H5652_001_0	5	4	Group 4	11	7b;7c;7d;7f;7i;14e1;17a;17b;18a;	7f_2;17a;18a;	2			1	40.00	40.00	2				2	
H5652	001	0	1	02	01	H5652_001_0	5	5	Group 5	01	12;		1	20	20	2			2				2	
H5652	001	0	1	02	01	H5652_001_0	5	6	Group 6	01	10a1;10a2;		2			1	175.00	175.00	2				2	
H5652	001	0	1	02	01	H5652_001_0	5	7	Group 7	10		18b;	2			1	99.00	1249.00	2				2	
H5652	001	0	1	02	01	H5652_001_0	5	8	Group 8	01	8b3;		2			1	30.00	30.00	2				2	
H5652	001	0	1	02	01	H5652_001_0	5	9	Group 9	01	7g;		2			1	0.00	40.00	2				2	
H5652	002	0	1	02	01	H5652_002_0	6	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7e;7h;8a1;8b1;8b2;9a1;9a2;9b;9c;9d;11a;11b;11c;14d;14e2;14e3;14e4;14e5;16b;	9d_2;14b;	1	40	40	2			2				2	
H5652	002	0	1	02	01	H5652_002_0	6	10	Group 10	01	7g;		2			1	50.00	85.00	2				2	
H5652	002	0	1	02	01	H5652_002_0	6	11	Group 11	10		16b;	1	0	50	2			2				2	
H5652	002	0	1	02	01	H5652_002_0	6	2	Group 2	01	14a;15;		1	0	40	2			2				2	
H5652	002	0	1	02	01	H5652_002_0	6	3	Group 3	11	7k;8a2;17b;	16a;17b;	2			1	0.00	0.00	2				2	
H5652	002	0	1	02	01	H5652_002_0	6	4	Group 4	11	7b;7c;7d;7f;7i;14e1;17a;18a;	7f_2;17a;18a;	2			1	85.00	85.00	2				2	
H5652	002	0	1	02	01	H5652_002_0	6	5	Group 5	01	12;		1	20	20	2			2				2	
H5652	002	0	1	02	01	H5652_002_0	6	6	Group 6	01	10a1;10a2;		2			1	275.00	275.00	2				2	
H5652	002	0	1	02	01	H5652_002_0	6	7	Group 7	10		18b;	2			1	99.00	1249.00	2				2	
H5652	002	0	1	02	01	H5652_002_0	6	8	Group 8	01	8b3;		2			1	30.00	30.00	2				2	
H5652	002	0	1	02	01	H5652_002_0	6	9	Group 9	01	7a;		2			1	50.00	50.00	2				2	
H5652	003	0	1	02	01	H5652_003_0	5	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7e;7h;8a1;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14d;14e2;14e3;14e4;14e5;16b;	9d_2;	1	30	30	2			2				2	
H5652	003	0	1	02	01	H5652_003_0	5	2	Group 2	01	14a;15;		1	0	30	2			2				2	
H5652	003	0	1	02	01	H5652_003_0	5	3	Group 3	11	7a;7k;8a2;10a1;10a2;12;	14b;16a;17b;	2			1	0.00	0.00	2				2	
H5652	003	0	1	02	01	H5652_003_0	5	4	Group 4	11	7b;7c;7d;7f;7i;14e1;17a;17b;18a;	7f_2;17a;18a;	2			1	35.00	35.00	2				2	
H5652	003	0	1	02	01	H5652_003_0	5	5	Group 5	10		18b;	2			1	99.00	1249.00	2				2	
H5652	003	0	1	02	01	H5652_003_0	5	6	Group 6	01	7g;		2			1	0.00	35.00	2				2	
H5652	003	0	1	02	01	H5652_003_0	5	7	Group 7	10		13b;14c8;	2			1	0.00	0.00	1	205.00	5		2	
H5652	003	0	1	02	01	H5652_003_0	5	8	Group 8	10		16b;	1	0	50	2			2				2	
H5652	004	0	1	02	01	H5652_004_0	5	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7e;7h;8a1;8b1;8b2;9a1;9a2;9b;9c;9d;11a;11b;11c;14d;14e2;14e3;14e4;14e5;16b;	9d_2;	1	30	30	2			2				2	
H5652	004	0	1	02	01	H5652_004_0	5	10	Group 10	10		13b;14c8;	2			1	0.00	0.00	1	80.00	5		2	
H5652	004	0	1	02	01	H5652_004_0	5	2	Group 2	01	14a;15;		1	0	30	2			2				2	
H5652	004	0	1	02	01	H5652_004_0	5	3	Group 3	11	7a;7k;8a2;17b;	14b;16a;17b;	2			1	0.00	0.00	2				2	
H5652	004	0	1	02	01	H5652_004_0	5	4	Group 4	11	7b;7c;7d;7f;7i;14e1;17a;18a;	7f_2;17a;18a;	2			1	60.00	60.00	2				2	
H5652	004	0	1	02	01	H5652_004_0	5	5	Group 5	01	12;		1	20	20	2			2				2	
H5652	004	0	1	02	01	H5652_004_0	5	6	Group 6	01	10a1;10a2;		2			1	175.00	175.00	2				2	
H5652	004	0	1	02	01	H5652_004_0	5	7	Group 7	10		18b;	2			1	99.00	1249.00	2				2	
H5652	004	0	1	02	01	H5652_004_0	5	8	Group 8	01	8b3;		2			1	30.00	30.00	2				2	
H5652	004	0	1	02	01	H5652_004_0	5	9	Group 9	01	7g;		2			1	0.00	60.00	2				2	
H5652	006	0	1	02	01	H5652_006_0	5	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7e;7h;8a1;8b1;8b2;9a1;9a2;9b;9c;9d;11a;11b;11c;14d;14e2;14e3;14e4;14e5;16b;	9d_2;14b;	1	30	30	2			2				2	
H5652	006	0	1	02	01	H5652_006_0	5	10	Group 10	10		16b;	1	0	50	2			2				2	
H5652	006	0	1	02	01	H5652_006_0	5	11	Group 11	10		13b;14c8;	2			1	0.00	0.00	1	40.00	5		2	
H5652	006	0	1	02	01	H5652_006_0	5	2	Group 2	01	14a;15;		1	0	30	2			2				2	
H5652	006	0	1	02	01	H5652_006_0	5	3	Group 3	11	7a;7k;8a2;17b;	16a;17b;	2			1	0.00	0.00	2				2	
H5652	006	0	1	02	01	H5652_006_0	5	4	Group 4	11	7b;7c;7d;7f;7i;14e1;17a;18a;	7f_2;17a;18a;	2			1	75.00	75.00	2				2	
H5652	006	0	1	02	01	H5652_006_0	5	5	Group 5	01	12;		1	20	20	2			2				2	
H5652	006	0	1	02	01	H5652_006_0	5	6	Group 6	01	10a1;10a2;		2			1	250.00	250.00	2				2	
H5652	006	0	1	02	01	H5652_006_0	5	7	Group 7	10		18b;	2			1	99.00	1249.00	2				2	
H5652	006	0	1	02	01	H5652_006_0	5	8	Group 8	01	8b3;		2			1	30.00	30.00	2				2	
H5652	006	0	1	02	01	H5652_006_0	5	9	Group 9	01	7g;		2			1	0.00	75.00	2				2	
H5652	008	0	1	02	01	H5652_008_0	5	1	Group 1	11	3-1;3-2;3-3;3-4;5;6;7e;7h;8a1;8b1;8b2;9a1;9a2;9b;9c;9d;11a;11b;11c;14d;14e2;14e3;14e4;14e5;16b;	9d_2;14b;	1	40	40	2			2				2	
H5652	008	0	1	02	01	H5652_008_0	5	10	Group 10	10		16b;	1	0	50	2			2				2	
H5652	008	0	1	02	01	H5652_008_0	5	11	Group 11	01	7a;		2			1	50.00	50.00	2				2	
H5652	008	0	1	02	01	H5652_008_0	5	2	Group 2	01	14a;15;		1	0	40	2			2				2	
H5652	008	0	1	02	01	H5652_008_0	5	3	Group 3	11	7k;8a2;17b;	16a;17b;	2			1	0.00	0.00	2				2	
H5652	008	0	1	02	01	H5652_008_0	5	4	Group 4	11	7b;7c;7d;7f;7i;14e1;17a;18a;	7f_2;17a;18a;	2			1	85.00	85.00	2				2	
H5652	008	0	1	02	01	H5652_008_0	5	5	Group 5	01	12;		1	20	20	2			2				2	
H5652	008	0	1	02	01	H5652_008_0	5	6	Group 6	01	10a1;10a2;		2			1	245.00	245.00	2				2	
H5652	008	0	1	02	01	H5652_008_0	5	7	Group 7	10		18b;	2			1	99.00	1249.00	2				2	
H5652	008	0	1	02	01	H5652_008_0	5	8	Group 8	01	8b3;		2			1	30.00	30.00	2				2	
H5652	008	0	1	02	01	H5652_008_0	5	9	Group 9	01	7g;		2			1	50.00	85.00	2				2	
H5774	027	0	1	02	01	H5774_027_0	5	1	35% coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	7b;7f_2;10b2;13a;14c2;14c17;16a;17a;18a;	1	35	35	2			2				2	
H5774	027	0	1	02	01	H5774_027_0	5	2	Hearing Aid	10		18b;	1	35	35	2			1	500.00	3		2	
H5774	027	0	1	02	01	H5774_027_0	5	3	Comprehensive Dental	10		16b;	1	35	35	2			1	3250.00	3		2	
H5774	027	0	1	02	01	H5774_027_0	5	4	Eyewear	10		17b;	1	35	35	2			1	500.00	3		2	
H5774	031	0	1	02	01	H5774_031_0	5	1	35% coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	7b;7f_2;10b2;13a;14c2;14c17;16a;17a;18a;	1	35	35	2			2				2	
H5774	031	0	1	02	01	H5774_031_0	5	2	Hearing Aid	10		18a2;18b;	1	35	35	2			1	1500.00	3		2	
H5774	031	0	1	02	01	H5774_031_0	5	3	Comprehensive Dental	10		16b;	1	35	35	2			1	3250.00	3		2	
H5774	031	0	1	02	01	H5774_031_0	5	4	Eyewear	10		17b;	1	35	35	2			1	600.00	3		2	
H5774	809	0	1	02	01	H5774_809_0	3	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H5774	809	0	1	02	01	H5774_809_0	3	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H5774	811	0	1	02	01	H5774_811_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H5774	811	0	1	02	01	H5774_811_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H5774	812	0	1	02	01	H5774_812_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H5774	812	0	1	02	01	H5774_812_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H5774	814	0	1	02	01	H5774_814_0	3	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H5774	814	0	1	02	01	H5774_814_0	3	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H5774	816	0	1	02	01	H5774_816_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H5774	816	0	1	02	01	H5774_816_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H5774	818	0	1	02	01	H5774_818_0	3	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H5774	818	0	1	02	01	H5774_818_0	3	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H5774	820	0	1	02	01	H5774_820_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H5774	820	0	1	02	01	H5774_820_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H5774	821	0	1	02	01	H5774_821_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H5774	821	0	1	02	01	H5774_821_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H5774	822	0	1	02	01	H5774_822_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H5774	822	0	1	02	01	H5774_822_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H5774	823	0	1	02	01	H5774_823_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H5774	823	0	1	02	01	H5774_823_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H5774	824	0	1	02	01	H5774_824_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H5774	824	0	1	02	01	H5774_824_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H5774	825	0	1	02	01	H5774_825_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H5774	825	0	1	02	01	H5774_825_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H5793	001	0	1	02	01	H5793_001_0	9	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H5793	010	0	1	02	01	H5793_010_0	10	1	0% Preventive Dental	10		16a;	1	0	0	2			2				2	
H5793	014	0	1	02	01	H5793_014_0	9	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H5793	016	0	1	02	01	H5793_016_0	9	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H5793	017	0	1	02	01	H5793_017_0	9	1	Dental POS	10		16a;16b;	2			1	0.00	0.00	2				2	
H5793	018	0	1	02	01	H5793_018_0	10	1	Dental POS	10		16a;16b;	2			1	0.00	0.00	2				2	
H5793	019	0	1	02	01	H5793_019_0	9	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H5793	020	0	1	02	01	H5793_020_0	8	1	Dental POS	10		16a;16b;	2			1	0.00	0.00	2				2	
H5828	012	1	1	02	01	H5828_012_1	8	1	40% COINSURANCE SERVICES	01	3-1;3-2;3-3;3-4;5;6;7b;7c;7e;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;		1	40	40	2			2				2	
H5828	012	1	1	02	01	H5828_012_1	8	2	7a/g PCP & OTHER HEALTH CARE PROF - $30	01	7a;7g;		2			1	30.00	30.00	2				2	
H5828	012	1	1	02	01	H5828_012_1	8	3	VARIOUS SPECIALISTS - $50	01	7d;7f;16b;17a;17b;18a;		2			1	50.00	50.00	2				2	
H5828	012	1	1	02	01	H5828_012_1	8	4	10a AMBULANCE (GROUND & AIR) - $295	01	10a1;10a2;		2			1	295.00	295.00	2				2	
H5828	012	1	1	02	01	H5828_012_1	8	5	12 DIALYSIS - 20%	01	12;		1	20	20	2			2				2	
H5828	012	1	1	02	01	H5828_012_1	8	6	$0 COPAY SERVICES	11	9d;	9d_2;	2			1	0.00	0.00	2				2	
H5828	012	1	1	02	01	H5828_012_1	8	7	15 MEDICARE PART B RX DRUGS	01	15;		1	0	40	1	35.00	35.00	2				2	
H5828	012	2	1	02	01	H5828_012_2	8	1	40% COINSURANCE SERVICES	01	3-1;3-2;3-3;3-4;5;6;7b;7c;7e;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;		1	40	40	2			2				2	
H5828	012	2	1	02	01	H5828_012_2	8	2	7a/g PCP & OTHER HEALTH CARE PROF - $30	01	7a;7g;		2			1	30.00	30.00	2				2	
H5828	012	2	1	02	01	H5828_012_2	8	3	VARIOUS SPECIALISTS - $50	01	7d;7f;16b;17a;17b;18a;		2			1	50.00	50.00	2				2	
H5828	012	2	1	02	01	H5828_012_2	8	4	10a AMBULANCE (GROUND & AIR) - $295	01	10a1;10a2;		2			1	295.00	295.00	2				2	
H5828	012	2	1	02	01	H5828_012_2	8	5	12 DIALYSIS - 20%	01	12;		1	20	20	2			2				2	
H5828	012	2	1	02	01	H5828_012_2	8	6	$0 COPAY SERVICES	11	9d;	9d_2;	2			1	0.00	0.00	2				2	
H5828	012	2	1	02	01	H5828_012_2	8	7	15 MEDICARE PART B RX DRUGS	01	15;		1	0	40	1	35.00	35.00	2				2	
H5828	012	3	1	02	01	H5828_012_3	8	1	40% COINSURANCE SERVICES	01	3-1;3-2;3-3;3-4;5;6;7b;7c;7e;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;		1	40	40	2			2				2	
H5828	012	3	1	02	01	H5828_012_3	8	2	7a/g PCP & OTHER HEALTH CARE PROF - $30	01	7a;7g;		2			1	30.00	30.00	2				2	
H5828	012	3	1	02	01	H5828_012_3	8	3	VARIOUS SPECIALISTS - $50	01	7d;7f;16b;17a;17b;18a;		2			1	50.00	50.00	2				2	
H5828	012	3	1	02	01	H5828_012_3	8	4	10a AMBULANCE (GROUND & AIR) - $295	01	10a1;10a2;		2			1	295.00	295.00	2				2	
H5828	012	3	1	02	01	H5828_012_3	8	5	12 DIALYSIS - 20%	01	12;		1	20	20	2			2				2	
H5828	012	3	1	02	01	H5828_012_3	8	6	$0 COPAY SERVICES	11	9d;	9d_2;	2			1	0.00	0.00	2				2	
H5828	012	3	1	02	01	H5828_012_3	8	7	15 MEDICARE PART B RX DRUGS	01	15;		1	0	40	1	35.00	35.00	2				2	
H5854	012	0	1	02	01	H5854_012_0	5	1	20% Coinsurance	01	3-1;3-2;3-3;3-4;5;7b;7c;7e;7f;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;10a1;10a2;11b;11c;14a;14e2;14e3;14e4;14e5;		1	20	20	2			2				2	
H5854	012	0	1	02	01	H5854_012_0	5	2	$0 Copay or 20% Coinsurance	01	7d;7g;		1	20	20	1	0.00	0.00	2				2	
H5854	012	0	1	02	01	H5854_012_0	5	3	$0 Copay	11	6;7a;9d;12;14d;	9d_2;	2			1	0.00	0.00	2				2	
H5854	012	0	1	02	01	H5854_012_0	5	4	Part B Rx Drugs	01	15;		1	0	20	1	35.00	35.00	2				2	
H5859	001	0	1	02	01	H5859_001_0	9	1	POS Group for OONet	01	7a;7d;7e;		1	20	20	2			2				2	
H5883	001	1	1	02	01	H5883_001_1	3	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;6;7k;8a2;9a2;9d;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c1;14c2;14c3;14c4;14c6;14c7;14c22;	2			2			2				2	
H5883	001	1	1	02	01	H5883_001_1	3	10	Point of Service Group 10	10		14c8;	2			2			1	100.00	3		2	
H5883	001	1	1	02	01	H5883_001_1	3	11	Point of Service Group 11	01	11a;11b;12;		1	0	20	2			2				2	
H5883	001	1	1	02	01	H5883_001_1	3	12	Point of Service Group 12	01	15;		1	20	20	2			2				2	
H5883	001	1	1	02	01	H5883_001_1	3	13	Point of Service Group 13	01	8b2;		2			1	25.00	25.00	2				2	
H5883	001	1	1	02	01	H5883_001_1	3	14	Point of Service Group 14	01	8a1;		2			1	0.00	20.00	2				2	
H5883	001	1	1	02	01	H5883_001_1	3	2	Point of Service Group 2	01	7b;		2			1	15.00	15.00	2				2	
H5883	001	1	1	02	01	H5883_001_1	3	3	Point of Service Group 3	10		16a;16b;	1	50	50	2			1	1500.00	3		2	
H5883	001	1	1	02	01	H5883_001_1	3	4	Point of Service Group 4	01	5;		2			1	55.00	55.00	2				2	
H5883	001	1	1	02	01	H5883_001_1	3	5	Point of Service Group 5	11	7a;7d;7e;7f;7g;7h;9c;17a;18a;	7b;13d;	2			1	0.00	35.00	2				2	
H5883	001	1	1	02	01	H5883_001_1	3	6	Point of Service Group 6	01	7c;7i;		2			1	30.00	30.00	2				2	
H5883	001	1	1	02	01	H5883_001_1	3	7	Point of Service Group 7	11	10a1;10a2;	13e;	2			1	250.00	250.00	2				2	
H5883	001	1	1	02	01	H5883_001_1	3	8	Point of Service Group 8	01	9a1;9b;16b;		2			1	0.00	200.00	2				2	
H5883	001	1	1	02	01	H5883_001_1	3	9	Point of Service Group 9	01	8b1;8b3;		2			1	20.00	100.00	2				2	
H5883	001	2	1	02	01	H5883_001_2	3	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;6;7k;8a2;9a2;9d;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c1;14c2;14c3;14c4;14c6;14c7;14c22;	2			2			2				2	
H5883	001	2	1	02	01	H5883_001_2	3	10	Point of Service Group 10	10		14c8;	2			2			1	100.00	3		2	
H5883	001	2	1	02	01	H5883_001_2	3	11	Point of Service Group 11	01	11a;11b;12;		1	0	20	2			2				2	
H5883	001	2	1	02	01	H5883_001_2	3	12	Point of Service Group 12	01	15;		1	20	20	2			2				2	
H5883	001	2	1	02	01	H5883_001_2	3	13	Point of Service Group 13	01	8b2;		2			1	25.00	25.00	2				2	
H5883	001	2	1	02	01	H5883_001_2	3	14	Point of Service Group 14	01	8a1;		2			1	0.00	20.00	2				2	
H5883	001	2	1	02	01	H5883_001_2	3	2	Point of Service Group 2	01	7b;		2			1	15.00	15.00	2				2	
H5883	001	2	1	02	01	H5883_001_2	3	3	Point of Service Group 3	10		16a;16b;	1	50	50	2			1	1500.00	3		2	
H5883	001	2	1	02	01	H5883_001_2	3	4	Point of Service Group 4	01	5;		2			1	55.00	55.00	2				2	
H5883	001	2	1	02	01	H5883_001_2	3	5	Point of Service Group 5	11	7a;7d;7e;7f;7g;7h;9c;17a;18a;	7b;13d;	2			1	0.00	35.00	2				2	
H5883	001	2	1	02	01	H5883_001_2	3	6	Point of Service Group 6	01	7c;7i;		2			1	30.00	30.00	2				2	
H5883	001	2	1	02	01	H5883_001_2	3	7	Point of Service Group 7	11	10a1;10a2;	13e;	2			1	250.00	250.00	2				2	
H5883	001	2	1	02	01	H5883_001_2	3	8	Point of Service Group 8	01	9a1;9b;16b;		2			1	0.00	200.00	2				2	
H5883	001	2	1	02	01	H5883_001_2	3	9	Point of Service Group 9	01	8b1;8b3;		2			1	20.00	100.00	2				2	
H5883	001	3	1	02	01	H5883_001_3	3	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;6;7k;8a2;9a2;9d;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c1;14c2;14c3;14c4;14c6;14c7;14c22;	2			2			2				2	
H5883	001	3	1	02	01	H5883_001_3	3	10	Point of Service Group 10	10		14c8;	2			2			1	100.00	3		2	
H5883	001	3	1	02	01	H5883_001_3	3	11	Point of Service Group 11	01	11a;11b;12;		1	0	20	2			2				2	
H5883	001	3	1	02	01	H5883_001_3	3	12	Point of Service Group 12	01	15;		1	20	20	2			2				2	
H5883	001	3	1	02	01	H5883_001_3	3	13	Point of Service Group 13	01	8b2;		2			1	25.00	25.00	2				2	
H5883	001	3	1	02	01	H5883_001_3	3	14	Point of Service Group 14	01	8a1;		2			1	0.00	20.00	2				2	
H5883	001	3	1	02	01	H5883_001_3	3	2	Point of Service Group 2	01	7b;		2			1	15.00	15.00	2				2	
H5883	001	3	1	02	01	H5883_001_3	3	3	Point of Service Group 3	10		16a;16b;	1	50	50	2			1	1500.00	3		2	
H5883	001	3	1	02	01	H5883_001_3	3	4	Point of Service Group 4	01	5;		2			1	55.00	55.00	2				2	
H5883	001	3	1	02	01	H5883_001_3	3	5	Point of Service Group 5	11	7a;7d;7e;7f;7g;7h;9c;17a;18a;	7b;	2			1	0.00	35.00	2				2	
H5883	001	3	1	02	01	H5883_001_3	3	6	Point of Service Group 6	01	7c;7i;		2			1	30.00	30.00	2				2	
H5883	001	3	1	02	01	H5883_001_3	3	7	Point of Service Group 7	11	10a1;10a2;	13e;	2			1	250.00	250.00	2				2	
H5883	001	3	1	02	01	H5883_001_3	3	8	Point of Service Group 8	01	9a1;9b;16b;		2			1	0.00	200.00	2				2	
H5883	001	3	1	02	01	H5883_001_3	3	9	Point of Service Group 9	01	8b1;8b3;		2			1	20.00	100.00	2				2	
H5883	001	4	1	02	01	H5883_001_4	3	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;6;7k;8a2;9a2;9d;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c1;14c2;14c3;14c4;14c6;14c7;14c22;	2			2			2				2	
H5883	001	4	1	02	01	H5883_001_4	3	10	Point of Service Group 10	10		14c8;	2			2			1	100.00	3		2	
H5883	001	4	1	02	01	H5883_001_4	3	11	Point of Service Group 11	01	11a;11b;12;		1	0	20	2			2				2	
H5883	001	4	1	02	01	H5883_001_4	3	12	Point of Service Group 12	01	15;		1	20	20	2			2				2	
H5883	001	4	1	02	01	H5883_001_4	3	13	Point of Service Group 13	01	8b2;		2			1	25.00	25.00	2				2	
H5883	001	4	1	02	01	H5883_001_4	3	14	Point of Service Group 14	01	8a1;		2			1	0.00	20.00	2				2	
H5883	001	4	1	02	01	H5883_001_4	3	2	Point of Service Group 2	01	7b;		2			1	15.00	15.00	2				2	
H5883	001	4	1	02	01	H5883_001_4	3	3	Point of Service Group 3	10		16a;16b;	1	50	50	2			1	1500.00	3		2	
H5883	001	4	1	02	01	H5883_001_4	3	4	Point of Service Group 4	01	5;		2			1	55.00	55.00	2				2	
H5883	001	4	1	02	01	H5883_001_4	3	5	Point of Service Group 5	11	7a;7d;7e;7f;7g;7h;9c;17a;18a;	7b;13d;	2			1	0.00	35.00	2				2	
H5883	001	4	1	02	01	H5883_001_4	3	6	Point of Service Group 6	01	7c;7i;		2			1	30.00	30.00	2				2	
H5883	001	4	1	02	01	H5883_001_4	3	7	Point of Service Group 7	11	10a1;10a2;	13e;	2			1	250.00	250.00	2				2	
H5883	001	4	1	02	01	H5883_001_4	3	8	Point of Service Group 8	01	9a1;9b;16b;		2			1	0.00	200.00	2				2	
H5883	001	4	1	02	01	H5883_001_4	3	9	Point of Service Group 9	01	8b1;8b3;		2			1	20.00	100.00	2				2	
H5883	001	5	1	02	01	H5883_001_5	3	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;6;7k;8a2;9a2;9d;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c1;14c2;14c3;14c4;14c6;14c7;14c22;	2			2			2				2	
H5883	001	5	1	02	01	H5883_001_5	3	10	Point of Service Group 10	10		14c8;	2			2			1	100.00	3		2	
H5883	001	5	1	02	01	H5883_001_5	3	11	Point of Service Group 11	01	11a;11b;12;		1	0	20	2			2				2	
H5883	001	5	1	02	01	H5883_001_5	3	12	Point of Service Group 12	01	15;		1	20	20	2			2				2	
H5883	001	5	1	02	01	H5883_001_5	3	13	Point of Service Group 13	01	8b2;		2			1	25.00	25.00	2				2	
H5883	001	5	1	02	01	H5883_001_5	3	14	Point of Service Group 14	01	8a1;		2			1	0.00	20.00	2				2	
H5883	001	5	1	02	01	H5883_001_5	3	2	Point of Service Group 2	01	7b;		2			1	15.00	15.00	2				2	
H5883	001	5	1	02	01	H5883_001_5	3	3	Point of Service Group 3	10		16a;16b;	1	50	50	2			1	1500.00	3		2	
H5883	001	5	1	02	01	H5883_001_5	3	4	Point of Service Group 4	01	5;		2			1	55.00	55.00	2				2	
H5883	001	5	1	02	01	H5883_001_5	3	5	Point of Service Group 5	11	7a;7d;7e;7f;7g;7h;9c;17a;18a;	7b;13d;	2			1	0.00	35.00	2				2	
H5883	001	5	1	02	01	H5883_001_5	3	6	Point of Service Group 6	01	7c;7i;		2			1	30.00	30.00	2				2	
H5883	001	5	1	02	01	H5883_001_5	3	7	Point of Service Group 7	11	10a1;10a2;	13e;	2			1	250.00	250.00	2				2	
H5883	001	5	1	02	01	H5883_001_5	3	8	Point of Service Group 8	01	9a1;9b;16b;		2			1	0.00	200.00	2				2	
H5883	001	5	1	02	01	H5883_001_5	3	9	Point of Service Group 9	01	8b1;8b3;		2			1	20.00	100.00	2				2	
H5883	002	1	1	02	01	H5883_002_1	5	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;6;7k;8a2;9a2;9d;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c1;14c2;14c3;14c4;14c6;14c7;14c11;14c22;	2			2			2				2	
H5883	002	1	1	02	01	H5883_002_1	5	10	Point of Service Group 10	01	15;		1	20	20	2			2				2	
H5883	002	1	1	02	01	H5883_002_1	5	11	Point of Service Group 11	01	11a;11b;12;		1	0	20	2			2				2	
H5883	002	1	1	02	01	H5883_002_1	5	12	Point of Service Group 12	01	7b;		2			1	15.00	15.00	2				2	
H5883	002	1	1	02	01	H5883_002_1	5	13	Point of Service Group 13	01	8b2;		2			1	15.00	15.00	2				2	
H5883	002	1	1	02	01	H5883_002_1	5	14	Point of Service Group 14	01	8a1;		2			1	0.00	20.00	2				2	
H5883	002	1	1	02	01	H5883_002_1	5	15	Point of Service Group 15	10		16a;16b;	1	50	50	2			1	1500.00	3		2	
H5883	002	1	1	02	01	H5883_002_1	5	2	Point of Service Group 2	11	17a;	7b;	2			1	0.00	35.00	2				2	
H5883	002	1	1	02	01	H5883_002_1	5	3	Point of Service Group 3	11	7a;7d;7e;7f;7g;7h;9c;18a;	13d;	2			1	35.00	35.00	2				2	
H5883	002	1	1	02	01	H5883_002_1	5	4	Point of Service Group 4	01	7c;7i;		2			1	30.00	30.00	2				2	
H5883	002	1	1	02	01	H5883_002_1	5	5	Point of Service Group 5	01	5;		2			1	55.00	55.00	2				2	
H5883	002	1	1	02	01	H5883_002_1	5	6	Point of Service Group 6	01	10a1;10a2;		2			1	250.00	250.00	2				2	
H5883	002	1	1	02	01	H5883_002_1	5	7	Point of Service Group 7	01	8b1;8b3;		2			1	20.00	75.00	2				2	
H5883	002	1	1	02	01	H5883_002_1	5	8	Point of Service Group 8	11	9a1;9b;16b;	13e;	2			1	0.00	225.00	2				2	
H5883	002	1	1	02	01	H5883_002_1	5	9	Point of Service Group 9	10		14c8;	2			2			1	100.00	3		2	
H5883	002	2	1	02	01	H5883_002_2	4	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;6;7k;8a2;9a2;9d;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c1;14c2;14c3;14c4;14c6;14c7;14c11;14c22;	2			2			2				2	
H5883	002	2	1	02	01	H5883_002_2	4	10	Point of Service Group 10	01	15;		1	20	20	2			2				2	
H5883	002	2	1	02	01	H5883_002_2	4	11	Point of Service Group 11	01	11a;11b;12;		1	0	20	2			2				2	
H5883	002	2	1	02	01	H5883_002_2	4	12	Point of Service Group 12	01	7b;		2			1	15.00	15.00	2				2	
H5883	002	2	1	02	01	H5883_002_2	4	13	Point of Service Group 13	01	8b2;		2			1	15.00	15.00	2				2	
H5883	002	2	1	02	01	H5883_002_2	4	14	Point of Service Group 14	01	8a1;		2			1	0.00	20.00	2				2	
H5883	002	2	1	02	01	H5883_002_2	4	15	Point of Service Group 15	10		16a;16b;	1	50	50	2			1	1500.00	3		2	
H5883	002	2	1	02	01	H5883_002_2	4	2	Point of Service Group 2	11	17a;	7b;	2			1	0.00	35.00	2				2	
H5883	002	2	1	02	01	H5883_002_2	4	3	Point of Service Group 3	11	7a;7d;7e;7f;7g;7h;9c;18a;	13d;	2			1	35.00	35.00	2				2	
H5883	002	2	1	02	01	H5883_002_2	4	4	Point of Service Group 4	01	7c;7i;		2			1	30.00	30.00	2				2	
H5883	002	2	1	02	01	H5883_002_2	4	5	Point of Service Group 5	01	5;		2			1	55.00	55.00	2				2	
H5883	002	2	1	02	01	H5883_002_2	4	6	Point of Service Group 6	01	10a1;10a2;		2			1	250.00	250.00	2				2	
H5883	002	2	1	02	01	H5883_002_2	4	7	Point of Service Group 7	01	8b1;8b3;		2			1	20.00	75.00	2				2	
H5883	002	2	1	02	01	H5883_002_2	4	8	Point of Service Group 8	11	9a1;9b;16b;	13e;	2			1	0.00	225.00	2				2	
H5883	002	2	1	02	01	H5883_002_2	4	9	Point of Service Group 9	10		14c8;	2			2			1	100.00	3		2	
H5883	002	3	1	02	01	H5883_002_3	4	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;6;7k;8a2;9a2;9d;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c1;14c2;14c3;14c4;14c6;14c7;14c11;14c22;	2			2			2				2	
H5883	002	3	1	02	01	H5883_002_3	4	10	Point of Service Group 10	01	15;		1	20	20	2			2				2	
H5883	002	3	1	02	01	H5883_002_3	4	11	Point of Service Group 11	01	11a;11b;12;		1	0	20	2			2				2	
H5883	002	3	1	02	01	H5883_002_3	4	12	Point of Service Group 12	01	7b;		2			1	15.00	15.00	2				2	
H5883	002	3	1	02	01	H5883_002_3	4	13	Point of Service Group 13	01	8b2;		2			1	15.00	15.00	2				2	
H5883	002	3	1	02	01	H5883_002_3	4	14	Point of Service Group 14	01	8a1;		2			1	0.00	20.00	2				2	
H5883	002	3	1	02	01	H5883_002_3	4	15	Point of Service Group 15	10		16a;16b;	1	50	50	2			1	1500.00	3		2	
H5883	002	3	1	02	01	H5883_002_3	4	2	Point of Service Group 2	11	17a;	7b;	2			1	0.00	35.00	2				2	
H5883	002	3	1	02	01	H5883_002_3	4	3	Point of Service Group 3	01	7a;7d;7e;7f;7g;7h;9c;18a;		2			1	35.00	35.00	2				2	
H5883	002	3	1	02	01	H5883_002_3	4	4	Point of Service Group 4	01	7c;7i;		2			1	30.00	30.00	2				2	
H5883	002	3	1	02	01	H5883_002_3	4	5	Point of Service Group 5	01	5;		2			1	55.00	55.00	2				2	
H5883	002	3	1	02	01	H5883_002_3	4	6	Point of Service Group 6	01	10a1;10a2;		2			1	250.00	250.00	2				2	
H5883	002	3	1	02	01	H5883_002_3	4	7	Point of Service Group 7	01	8b1;8b3;		2			1	20.00	75.00	2				2	
H5883	002	3	1	02	01	H5883_002_3	4	8	Point of Service Group 8	11	9a1;9b;16b;	13e;	2			1	0.00	225.00	2				2	
H5883	002	3	1	02	01	H5883_002_3	4	9	Point of Service Group 9	10		14c8;	2			2			1	100.00	3		2	
H5883	002	4	1	02	01	H5883_002_4	4	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;6;7k;8a2;9a2;9d;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c1;14c2;14c3;14c4;14c6;14c7;14c11;14c22;	2			2			2				2	
H5883	002	4	1	02	01	H5883_002_4	4	10	Point of Service Group 10	01	15;		1	20	20	2			2				2	
H5883	002	4	1	02	01	H5883_002_4	4	11	Point of Service Group 11	01	11a;11b;12;		1	0	20	2			2				2	
H5883	002	4	1	02	01	H5883_002_4	4	12	Point of Service Group 12	01	7b;		2			1	15.00	15.00	2				2	
H5883	002	4	1	02	01	H5883_002_4	4	13	Point of Service Group 13	01	8b2;		2			1	15.00	15.00	2				2	
H5883	002	4	1	02	01	H5883_002_4	4	14	Point of Service Group 14	01	8a1;		2			1	0.00	20.00	2				2	
H5883	002	4	1	02	01	H5883_002_4	4	15	Point of Service Group 15	10		16a;16b;	1	50	50	2			1	1500.00	3		2	
H5883	002	4	1	02	01	H5883_002_4	4	2	Point of Service Group 2	11	17a;	7b;	2			1	0.00	35.00	2				2	
H5883	002	4	1	02	01	H5883_002_4	4	3	Point of Service Group 3	11	7a;7d;7e;7f;7g;7h;9c;18a;	13d;	2			1	35.00	35.00	2				2	
H5883	002	4	1	02	01	H5883_002_4	4	4	Point of Service Group 4	01	7c;7i;		2			1	30.00	30.00	2				2	
H5883	002	4	1	02	01	H5883_002_4	4	5	Point of Service Group 5	01	5;		2			1	55.00	55.00	2				2	
H5883	002	4	1	02	01	H5883_002_4	4	6	Point of Service Group 6	01	10a1;10a2;		2			1	250.00	250.00	2				2	
H5883	002	4	1	02	01	H5883_002_4	4	7	Point of Service Group 7	01	8b1;8b3;		2			1	20.00	75.00	2				2	
H5883	002	4	1	02	01	H5883_002_4	4	8	Point of Service Group 8	11	9a1;9b;16b;	13e;	2			1	0.00	225.00	2				2	
H5883	002	4	1	02	01	H5883_002_4	4	9	Point of Service Group 9	10		14c8;	2			2			1	100.00	3		2	
H5883	002	7	1	02	01	H5883_002_7	4	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;6;7k;8a2;9a2;9d;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c1;14c2;14c3;14c4;14c6;14c7;14c11;14c22;	2			2			2				2	
H5883	002	7	1	02	01	H5883_002_7	4	10	Point of Service Group 10	01	15;		1	20	20	2			2				2	
H5883	002	7	1	02	01	H5883_002_7	4	11	Point of Service Group 11	01	11a;11b;12;		1	0	20	2			2				2	
H5883	002	7	1	02	01	H5883_002_7	4	12	Point of Service Group 12	01	7b;		2			1	15.00	15.00	2				2	
H5883	002	7	1	02	01	H5883_002_7	4	13	Point of Service Group 13	01	8b2;		2			1	15.00	15.00	2				2	
H5883	002	7	1	02	01	H5883_002_7	4	14	Point of Service Group 14	01	8a1;		2			1	0.00	20.00	2				2	
H5883	002	7	1	02	01	H5883_002_7	4	15	Point of Service Group 15	10		16a;16b;	1	50	50	2			1	1500.00	3		2	
H5883	002	7	1	02	01	H5883_002_7	4	2	Point of Service Group 2	11	17a;	7b;	2			1	0.00	35.00	2				2	
H5883	002	7	1	02	01	H5883_002_7	4	3	Point of Service Group 3	11	7a;7d;7e;7f;7g;7h;9c;18a;	13d;	2			1	35.00	35.00	2				2	
H5883	002	7	1	02	01	H5883_002_7	4	4	Point of Service Group 4	01	7c;7i;		2			1	30.00	30.00	2				2	
H5883	002	7	1	02	01	H5883_002_7	4	5	Point of Service Group 5	01	5;		2			1	55.00	55.00	2				2	
H5883	002	7	1	02	01	H5883_002_7	4	6	Point of Service Group 6	01	10a1;10a2;		2			1	250.00	250.00	2				2	
H5883	002	7	1	02	01	H5883_002_7	4	7	Point of Service Group 7	01	8b1;8b3;		2			1	20.00	75.00	2				2	
H5883	002	7	1	02	01	H5883_002_7	4	8	Point of Service Group 8	11	9a1;9b;16b;	13e;	2			1	0.00	225.00	2				2	
H5883	002	7	1	02	01	H5883_002_7	4	9	Point of Service Group 9	10		14c8;	2			2			1	100.00	3		2	
H5883	003	1	1	02	01	H5883_003_1	4	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;6;7k;8a2;8b2;9a2;9d;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c1;14c2;14c3;14c4;14c6;14c7;14c11;14c22;	2			2			2				2	
H5883	003	1	1	02	01	H5883_003_1	4	10	Point of Service Group 10	10		14c8;	2			2			1	100.00	3		2	
H5883	003	1	1	02	01	H5883_003_1	4	11	Point of Service Group 11	01	15;		1	20	20	2			2				2	
H5883	003	1	1	02	01	H5883_003_1	4	12	Point of Service Group 12	01	11a;11b;12;		1	0	20	2			2				2	
H5883	003	1	1	02	01	H5883_003_1	4	13	Point of Service Group 13	10		16a;16b;	1	50	50	2			1	1500.00	3		2	
H5883	003	1	1	02	01	H5883_003_1	4	2	Point of Service Group 2	01	8a1;		2			1	0.00	10.00	2				2	
H5883	003	1	1	02	01	H5883_003_1	4	3	Point of Service Group 3	11	7a;7d;7e;7f;7g;7h;9c;18a;	13d;	2			1	20.00	20.00	2				2	
H5883	003	1	1	02	01	H5883_003_1	4	4	Point of Service Group 4	11	17a;	7b;	2			1	0.00	20.00	2				2	
H5883	003	1	1	02	01	H5883_003_1	4	5	Point of Service Group 5	01	7b;7c;7i;		2			1	15.00	15.00	2				2	
H5883	003	1	1	02	01	H5883_003_1	4	6	Point of Service Group 6	01	5;		2			1	55.00	55.00	2				2	
H5883	003	1	1	02	01	H5883_003_1	4	7	Point of Service Group 7	11	9a1;9b;16b;	13e;	2			1	0.00	200.00	2				2	
H5883	003	1	1	02	01	H5883_003_1	4	8	Point of Service Group 8	01	10a1;10a2;		2			1	250.00	250.00	2				2	
H5883	003	1	1	02	01	H5883_003_1	4	9	Point of Service Group 9	01	8b1;8b3;		2			1	10.00	50.00	2				2	
H5883	003	2	1	02	01	H5883_003_2	4	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;6;7k;8a2;8b2;9a2;9d;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c1;14c2;14c3;14c4;14c6;14c7;14c11;14c22;	2			2			2				2	
H5883	003	2	1	02	01	H5883_003_2	4	10	Point of Service Group 10	10		14c8;	2			2			1	100.00	3		2	
H5883	003	2	1	02	01	H5883_003_2	4	11	Point of Service Group 11	01	15;		1	20	20	2			2				2	
H5883	003	2	1	02	01	H5883_003_2	4	12	Point of Service Group 12	01	11a;11b;12;		1	0	20	2			2				2	
H5883	003	2	1	02	01	H5883_003_2	4	13	Point of Service Group 13	10		16a;16b;	1	50	50	2			1	1500.00	3		2	
H5883	003	2	1	02	01	H5883_003_2	4	2	Point of Service Group 2	01	8a1;		2			1	0.00	10.00	2				2	
H5883	003	2	1	02	01	H5883_003_2	4	3	Point of Service Group 3	11	7a;7d;7e;7f;7g;7h;9c;18a;	13d;	2			1	20.00	20.00	2				2	
H5883	003	2	1	02	01	H5883_003_2	4	4	Point of Service Group 4	11	17a;	7b;	2			1	0.00	20.00	2				2	
H5883	003	2	1	02	01	H5883_003_2	4	5	Point of Service Group 5	01	7b;7c;7i;		2			1	15.00	15.00	2				2	
H5883	003	2	1	02	01	H5883_003_2	4	6	Point of Service Group 6	01	5;		2			1	55.00	55.00	2				2	
H5883	003	2	1	02	01	H5883_003_2	4	7	Point of Service Group 7	11	9a1;9b;16b;	13e;	2			1	0.00	200.00	2				2	
H5883	003	2	1	02	01	H5883_003_2	4	8	Point of Service Group 8	01	10a1;10a2;		2			1	250.00	250.00	2				2	
H5883	003	2	1	02	01	H5883_003_2	4	9	Point of Service Group 9	01	8b1;8b3;		2			1	10.00	50.00	2				2	
H5883	003	3	1	02	01	H5883_003_3	4	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;6;7k;8a2;8b2;9a2;9d;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c1;14c2;14c3;14c4;14c6;14c7;14c11;14c22;	2			2			2				2	
H5883	003	3	1	02	01	H5883_003_3	4	10	Point of Service Group 10	10		14c8;	2			2			1	100.00	3		2	
H5883	003	3	1	02	01	H5883_003_3	4	11	Point of Service Group 11	01	15;		1	20	20	2			2				2	
H5883	003	3	1	02	01	H5883_003_3	4	12	Point of Service Group 12	01	11a;11b;12;		1	0	20	2			2				2	
H5883	003	3	1	02	01	H5883_003_3	4	13	Point of Service Group 13	10		16a;16b;	1	50	50	2			1	1500.00	3		2	
H5883	003	3	1	02	01	H5883_003_3	4	2	Point of Service Group 2	01	8a1;		2			1	0.00	10.00	2				2	
H5883	003	3	1	02	01	H5883_003_3	4	3	Point of Service Group 3	01	7a;7d;7e;7f;7g;7h;9c;18a;		2			1	20.00	20.00	2				2	
H5883	003	3	1	02	01	H5883_003_3	4	4	Point of Service Group 4	11	17a;	7b;	2			1	0.00	20.00	2				2	
H5883	003	3	1	02	01	H5883_003_3	4	5	Point of Service Group 5	01	7b;7c;7i;		2			1	15.00	15.00	2				2	
H5883	003	3	1	02	01	H5883_003_3	4	6	Point of Service Group 6	01	5;		2			1	55.00	55.00	2				2	
H5883	003	3	1	02	01	H5883_003_3	4	7	Point of Service Group 7	11	9a1;9b;16b;	13e;	2			1	0.00	200.00	2				2	
H5883	003	3	1	02	01	H5883_003_3	4	8	Point of Service Group 8	01	10a1;10a2;		2			1	250.00	250.00	2				2	
H5883	003	3	1	02	01	H5883_003_3	4	9	Point of Service Group 9	01	8b1;8b3;		2			1	10.00	50.00	2				2	
H5883	003	4	1	02	01	H5883_003_4	4	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;6;7k;8a2;8b2;9a2;9d;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c1;14c2;14c3;14c4;14c6;14c7;14c11;14c22;	2			2			2				2	
H5883	003	4	1	02	01	H5883_003_4	4	10	Point of Service Group 10	10		14c8;	2			2			1	100.00	3		2	
H5883	003	4	1	02	01	H5883_003_4	4	11	Point of Service Group 11	01	15;		1	20	20	2			2				2	
H5883	003	4	1	02	01	H5883_003_4	4	12	Point of Service Group 12	01	11a;11b;12;		1	0	20	2			2				2	
H5883	003	4	1	02	01	H5883_003_4	4	13	Point of Service Group 13	10		16a;16b;	1	50	50	2			1	1500.00	3		2	
H5883	003	4	1	02	01	H5883_003_4	4	2	Point of Service Group 2	01	8a1;		2			1	0.00	10.00	2				2	
H5883	003	4	1	02	01	H5883_003_4	4	3	Point of Service Group 3	11	7a;7d;7e;7f;7g;7h;9c;18a;	13d;	2			1	20.00	20.00	2				2	
H5883	003	4	1	02	01	H5883_003_4	4	4	Point of Service Group 4	11	17a;	7b;	2			1	0.00	20.00	2				2	
H5883	003	4	1	02	01	H5883_003_4	4	5	Point of Service Group 5	01	7b;7c;7i;		2			1	15.00	15.00	2				2	
H5883	003	4	1	02	01	H5883_003_4	4	6	Point of Service Group 6	01	5;		2			1	55.00	55.00	2				2	
H5883	003	4	1	02	01	H5883_003_4	4	7	Point of Service Group 7	11	9a1;9b;16b;	13e;	2			1	0.00	200.00	2				2	
H5883	003	4	1	02	01	H5883_003_4	4	8	Point of Service Group 8	01	10a1;10a2;		2			1	250.00	250.00	2				2	
H5883	003	4	1	02	01	H5883_003_4	4	9	Point of Service Group 9	01	8b1;8b3;		2			1	10.00	50.00	2				2	
H5883	003	5	1	02	01	H5883_003_5	4	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;6;7k;8a2;8b2;9a2;9d;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c1;14c2;14c3;14c4;14c6;14c7;14c11;14c22;	2			2			2				2	
H5883	003	5	1	02	01	H5883_003_5	4	10	Point of Service Group 10	10		14c8;	2			2			1	100.00	3		2	
H5883	003	5	1	02	01	H5883_003_5	4	11	Point of Service Group 11	01	15;		1	20	20	2			2				2	
H5883	003	5	1	02	01	H5883_003_5	4	12	Point of Service Group 12	01	11a;11b;12;		1	0	20	2			2				2	
H5883	003	5	1	02	01	H5883_003_5	4	13	Point of Service Group 13	10		16a;16b;	1	50	50	2			1	1500.00	3		2	
H5883	003	5	1	02	01	H5883_003_5	4	2	Point of Service Group 2	01	8a1;		2			1	0.00	10.00	2				2	
H5883	003	5	1	02	01	H5883_003_5	4	3	Point of Service Group 3	11	7a;7d;7e;7f;7g;7h;9c;18a;	13d;	2			1	20.00	20.00	2				2	
H5883	003	5	1	02	01	H5883_003_5	4	4	Point of Service Group 4	11	17a;	7b;	2			1	0.00	20.00	2				2	
H5883	003	5	1	02	01	H5883_003_5	4	5	Point of Service Group 5	01	7b;7c;7i;		2			1	15.00	15.00	2				2	
H5883	003	5	1	02	01	H5883_003_5	4	6	Point of Service Group 6	01	5;		2			1	55.00	55.00	2				2	
H5883	003	5	1	02	01	H5883_003_5	4	7	Point of Service Group 7	11	9a1;9b;16b;	13e;	2			1	0.00	200.00	2				2	
H5883	003	5	1	02	01	H5883_003_5	4	8	Point of Service Group 8	01	10a1;10a2;		2			1	250.00	250.00	2				2	
H5883	003	5	1	02	01	H5883_003_5	4	9	Point of Service Group 9	01	8b1;8b3;		2			1	10.00	50.00	2				2	
H5883	012	1	1	02	01	H5883_012_1	5	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;8b1;8b2;8b3;9a1;9b;9c;11c;12;17a;17b;18a;	13d;14b;	1	35	35	2			2				2	
H5883	012	1	1	02	01	H5883_012_1	5	2	Point of Service Group 2	11	6;7k;9d;14a;14d;14e1;14e2;14e3;14e4;14e5;	9d_2;14c1;14c2;14c3;14c4;14c6;14c7;14c22;	2			2			2				2	
H5883	012	1	1	02	01	H5883_012_1	5	3	Point of Service Group 3	11	9a2;	13e;	2			1	90.00	90.00	2				2	
H5883	012	1	1	02	01	H5883_012_1	5	4	Point of Service Group 4	01	10a1;10a2;		2			1	250.00	250.00	2				2	
H5883	012	1	1	02	01	H5883_012_1	5	5	Point of Service Group 5	01	11a;11b;		1	0	20	2			2				2	
H5883	012	1	1	02	01	H5883_012_1	5	6	Point of Service Group 6	01	15;		1	20	20	2			2				2	
H5883	012	1	1	02	01	H5883_012_1	5	7	Point of Service Group 7	11	16b;	16a;16b;	1	50	50	2			2				2	
H5883	012	1	1	02	01	H5883_012_1	5	8	Point of Service Group 8	01	8a1;		1	0	35	2			2				2	
H5883	012	2	1	02	01	H5883_012_2	5	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;8b1;8b2;8b3;9a1;9b;9c;11c;12;17a;17b;18a;	13d;14b;	1	35	35	2			2				2	
H5883	012	2	1	02	01	H5883_012_2	5	2	Point of Service Group 2	11	6;7k;9d;14a;14d;14e1;14e2;14e3;14e4;14e5;	9d_2;14c1;14c2;14c3;14c4;14c6;14c7;14c22;	2			2			2				2	
H5883	012	2	1	02	01	H5883_012_2	5	3	Point of Service Group 3	11	9a2;	13e;	2			1	90.00	90.00	2				2	
H5883	012	2	1	02	01	H5883_012_2	5	4	Point of Service Group 4	01	10a1;10a2;		2			1	250.00	250.00	2				2	
H5883	012	2	1	02	01	H5883_012_2	5	5	Point of Service Group 5	01	11a;11b;		1	0	20	2			2				2	
H5883	012	2	1	02	01	H5883_012_2	5	6	Point of Service Group 6	01	15;		1	20	20	2			2				2	
H5883	012	2	1	02	01	H5883_012_2	5	7	Point of Service Group 7	11	16b;	16a;16b;	1	50	50	2			2				2	
H5883	012	2	1	02	01	H5883_012_2	5	8	Point of Service Group 8	01	8a1;		1	0	35	2			2				2	
H5883	014	1	1	02	01	H5883_014_1	5	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;6;7a;7k;8a2;9a2;9d;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c1;14c2;14c3;14c4;14c6;14c7;14c22;	2			2			2				2	
H5883	014	1	1	02	01	H5883_014_1	5	10	Point of Service Group 10	01	8b1;8b3;		2			1	20.00	100.00	2				2	
H5883	014	1	1	02	01	H5883_014_1	5	11	Point of Service Group 11	11	7b;17a;	7b;	2			1	0.00	45.00	2				2	
H5883	014	1	1	02	01	H5883_014_1	5	12	Point of Service Group 12	10		14c8;	2			2			1	100.00	3		2	
H5883	014	1	1	02	01	H5883_014_1	5	13	Point of Service Group 13	01	11a;11b;12;		1	0	20	2			2				2	
H5883	014	1	1	02	01	H5883_014_1	5	14	Point of Service Group 14	01	8b2;		2			1	25.00	25.00	2				2	
H5883	014	1	1	02	01	H5883_014_1	5	15	Point of Service Group 15	01	8a1;		2			1	0.00	20.00	2				2	
H5883	014	1	1	02	01	H5883_014_1	5	2	Point of Service Group 2	01	15;		1	20	20	2			2				2	
H5883	014	1	1	02	01	H5883_014_1	5	3	Point of Service Group 3	01	7d;7f;7g;9c;18a;		2			1	45.00	45.00	2				2	
H5883	014	1	1	02	01	H5883_014_1	5	4	Point of Service Group 4	10		16a;16b;	1	50	50	2			1	1500.00	3		2	
H5883	014	1	1	02	01	H5883_014_1	5	5	Point of Service Group 5	01	7c;7i;		2			1	30.00	30.00	2				2	
H5883	014	1	1	02	01	H5883_014_1	5	6	Point of Service Group 6	11	7e;7h;	13d;	2			1	40.00	40.00	2				2	
H5883	014	1	1	02	01	H5883_014_1	5	7	Point of Service Group 7	01	5;		2			1	55.00	55.00	2				2	
H5883	014	1	1	02	01	H5883_014_1	5	8	Point of Service Group 8	11	9a1;9b;16b;	13e;	2			1	0.00	275.00	2				2	
H5883	014	1	1	02	01	H5883_014_1	5	9	Point of Service Group 9	01	10a1;10a2;		2			1	275.00	275.00	2				2	
H5883	014	2	1	02	01	H5883_014_2	5	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;6;7a;7k;8a2;9a2;9d;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c1;14c2;14c3;14c4;14c6;14c7;14c22;	2			2			2				2	
H5883	014	2	1	02	01	H5883_014_2	5	10	Point of Service Group 10	01	8b1;8b3;		2			1	20.00	100.00	2				2	
H5883	014	2	1	02	01	H5883_014_2	5	11	Point of Service Group 11	11	7b;17a;	7b;	2			1	0.00	45.00	2				2	
H5883	014	2	1	02	01	H5883_014_2	5	12	Point of Service Group 12	10		14c8;	2			2			1	100.00	3		2	
H5883	014	2	1	02	01	H5883_014_2	5	13	Point of Service Group 13	01	11a;11b;12;		1	0	20	2			2				2	
H5883	014	2	1	02	01	H5883_014_2	5	14	Point of Service Group 14	01	8b2;		2			1	25.00	25.00	2				2	
H5883	014	2	1	02	01	H5883_014_2	5	15	Point of Service Group 15	01	8a1;		2			1	0.00	20.00	2				2	
H5883	014	2	1	02	01	H5883_014_2	5	2	Point of Service Group 2	01	15;		1	20	20	2			2				2	
H5883	014	2	1	02	01	H5883_014_2	5	3	Point of Service Group 3	01	7d;7f;7g;9c;18a;		2			1	45.00	45.00	2				2	
H5883	014	2	1	02	01	H5883_014_2	5	4	Point of Service Group 4	10		16a;16b;	1	50	50	2			1	1500.00	3		2	
H5883	014	2	1	02	01	H5883_014_2	5	5	Point of Service Group 5	01	7c;7i;		2			1	30.00	30.00	2				2	
H5883	014	2	1	02	01	H5883_014_2	5	6	Point of Service Group 6	11	7e;7h;	13d;	2			1	40.00	40.00	2				2	
H5883	014	2	1	02	01	H5883_014_2	5	7	Point of Service Group 7	01	5;		2			1	55.00	55.00	2				2	
H5883	014	2	1	02	01	H5883_014_2	5	8	Point of Service Group 8	11	9a1;9b;16b;	13e;	2			1	0.00	275.00	2				2	
H5883	014	2	1	02	01	H5883_014_2	5	9	Point of Service Group 9	01	10a1;10a2;		2			1	275.00	275.00	2				2	
H5883	014	3	1	02	01	H5883_014_3	5	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;6;7a;7k;8a2;9a2;9d;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c1;14c2;14c3;14c4;14c6;14c7;14c22;	2			2			2				2	
H5883	014	3	1	02	01	H5883_014_3	5	10	Point of Service Group 10	01	8b1;8b3;		2			1	20.00	100.00	2				2	
H5883	014	3	1	02	01	H5883_014_3	5	11	Point of Service Group 11	11	7b;17a;	7b;	2			1	0.00	45.00	2				2	
H5883	014	3	1	02	01	H5883_014_3	5	12	Point of Service Group 12	10		14c8;	2			2			1	100.00	3		2	
H5883	014	3	1	02	01	H5883_014_3	5	13	Point of Service Group 13	01	11a;11b;12;		1	0	20	2			2				2	
H5883	014	3	1	02	01	H5883_014_3	5	14	Point of Service Group 14	01	8b2;		2			1	25.00	25.00	2				2	
H5883	014	3	1	02	01	H5883_014_3	5	15	Point of Service Group 15	01	8a1;		2			1	0.00	20.00	2				2	
H5883	014	3	1	02	01	H5883_014_3	5	2	Point of Service Group 2	01	15;		1	20	20	2			2				2	
H5883	014	3	1	02	01	H5883_014_3	5	3	Point of Service Group 3	01	7d;7f;7g;9c;18a;		2			1	45.00	45.00	2				2	
H5883	014	3	1	02	01	H5883_014_3	5	4	Point of Service Group 4	10		16a;16b;	1	50	50	2			1	1500.00	3		2	
H5883	014	3	1	02	01	H5883_014_3	5	5	Point of Service Group 5	01	7c;7i;		2			1	30.00	30.00	2				2	
H5883	014	3	1	02	01	H5883_014_3	5	6	Point of Service Group 6	01	7e;7h;		2			1	40.00	40.00	2				2	
H5883	014	3	1	02	01	H5883_014_3	5	7	Point of Service Group 7	01	5;		2			1	55.00	55.00	2				2	
H5883	014	3	1	02	01	H5883_014_3	5	8	Point of Service Group 8	11	9a1;9b;16b;	13e;	2			1	0.00	275.00	2				2	
H5883	014	3	1	02	01	H5883_014_3	5	9	Point of Service Group 9	01	10a1;10a2;		2			1	275.00	275.00	2				2	
H5883	014	4	1	02	01	H5883_014_4	5	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;6;7a;7k;8a2;9a2;9d;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c1;14c2;14c3;14c4;14c6;14c7;14c22;	2			2			2				2	
H5883	014	4	1	02	01	H5883_014_4	5	10	Point of Service Group 10	01	8b1;8b3;		2			1	20.00	100.00	2				2	
H5883	014	4	1	02	01	H5883_014_4	5	11	Point of Service Group 11	11	7b;17a;	7b;	2			1	0.00	45.00	2				2	
H5883	014	4	1	02	01	H5883_014_4	5	12	Point of Service Group 12	10		14c8;	2			2			1	100.00	3		2	
H5883	014	4	1	02	01	H5883_014_4	5	13	Point of Service Group 13	01	11a;11b;12;		1	0	20	2			2				2	
H5883	014	4	1	02	01	H5883_014_4	5	14	Point of Service Group 14	01	8b2;		2			1	25.00	25.00	2				2	
H5883	014	4	1	02	01	H5883_014_4	5	15	Point of Service Group 15	01	8a1;		2			1	0.00	20.00	2				2	
H5883	014	4	1	02	01	H5883_014_4	5	2	Point of Service Group 2	01	15;		1	20	20	2			2				2	
H5883	014	4	1	02	01	H5883_014_4	5	3	Point of Service Group 3	01	7d;7f;7g;9c;18a;		2			1	45.00	45.00	2				2	
H5883	014	4	1	02	01	H5883_014_4	5	4	Point of Service Group 4	10		16a;16b;	1	50	50	2			1	1500.00	3		2	
H5883	014	4	1	02	01	H5883_014_4	5	5	Point of Service Group 5	01	7c;7i;		2			1	30.00	30.00	2				2	
H5883	014	4	1	02	01	H5883_014_4	5	6	Point of Service Group 6	11	7e;7h;	13d;	2			1	40.00	40.00	2				2	
H5883	014	4	1	02	01	H5883_014_4	5	7	Point of Service Group 7	01	5;		2			1	55.00	55.00	2				2	
H5883	014	4	1	02	01	H5883_014_4	5	8	Point of Service Group 8	11	9a1;9b;16b;	13e;	2			1	0.00	275.00	2				2	
H5883	014	4	1	02	01	H5883_014_4	5	9	Point of Service Group 9	01	10a1;10a2;		2			1	275.00	275.00	2				2	
H5883	014	5	1	02	01	H5883_014_5	5	1	Point of Service Group 1	11	3-1;3-2;3-3;3-4;6;7a;7k;8a2;9a2;9d;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;14c1;14c2;14c3;14c4;14c6;14c7;14c22;	2			2			2				2	
H5883	014	5	1	02	01	H5883_014_5	5	10	Point of Service Group 10	01	8b1;8b3;		2			1	20.00	100.00	2				2	
H5883	014	5	1	02	01	H5883_014_5	5	11	Point of Service Group 11	11	7b;17a;	7b;	2			1	0.00	45.00	2				2	
H5883	014	5	1	02	01	H5883_014_5	5	12	Point of Service Group 12	10		14c8;	2			2			1	100.00	3		2	
H5883	014	5	1	02	01	H5883_014_5	5	13	Point of Service Group 13	01	11a;11b;12;		1	0	20	2			2				2	
H5883	014	5	1	02	01	H5883_014_5	5	14	Point of Service Group 14	01	8b2;		2			1	25.00	25.00	2				2	
H5883	014	5	1	02	01	H5883_014_5	5	15	Point of Service Group 15	01	8a1;		2			1	0.00	20.00	2				2	
H5883	014	5	1	02	01	H5883_014_5	5	2	Point of Service Group 2	01	15;		1	20	20	2			2				2	
H5883	014	5	1	02	01	H5883_014_5	5	3	Point of Service Group 3	01	7d;7f;7g;9c;18a;		2			1	45.00	45.00	2				2	
H5883	014	5	1	02	01	H5883_014_5	5	4	Point of Service Group 4	10		16a;16b;	1	50	50	2			1	1500.00	3		2	
H5883	014	5	1	02	01	H5883_014_5	5	5	Point of Service Group 5	01	7c;7i;		2			1	30.00	30.00	2				2	
H5883	014	5	1	02	01	H5883_014_5	5	6	Point of Service Group 6	11	7e;7h;	13d;	2			1	40.00	40.00	2				2	
H5883	014	5	1	02	01	H5883_014_5	5	7	Point of Service Group 7	01	5;		2			1	55.00	55.00	2				2	
H5883	014	5	1	02	01	H5883_014_5	5	8	Point of Service Group 8	11	9a1;9b;16b;	13e;	2			1	0.00	275.00	2				2	
H5883	014	5	1	02	01	H5883_014_5	5	9	Point of Service Group 9	01	10a1;10a2;		2			1	275.00	275.00	2				2	
H5883	801	0	1	02	01	H5883_801_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H5883	801	0	1	02	01	H5883_801_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H5883	805	0	1	02	01	H5883_805_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H5883	805	0	1	02	01	H5883_805_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H5943	001	0	1	02	01	H5943_001_0	6	1	$0	11	5;7a;7c;7e;7h;7i;8a2;9d;11c;14a;14e1;14e2;14e3;14e4;14e5;	14b;	2			2			2				2	
H5943	001	0	1	02	01	H5943_001_0	6	2	0%-20%	01	7g;11a;11b;15;		1	0	20	2			2				2	
H5943	001	0	1	02	01	H5943_001_0	6	3	20%	01	3-1;3-2;3-3;3-4;7b;7d;7f;7k;8a1;8b1;8b2;8b3;9a1;9a2;9b;9c;10a1;10a2;12;14d;16b;17a;17b;18a;		1	20	20	2			2				2	
H5943	002	0	1	02	01	H5943_002_0	7	1	$0	11	5;7e;7h;8a2;9d;11c;14a;14e1;14e2;14e3;14e4;14e5;	14b;	2			2			2				2	
H5943	002	0	1	02	01	H5943_002_0	7	2	0%-20%	01	7d;7g;11a;11b;15;		1	0	20	2			2				2	
H5943	002	0	1	02	01	H5943_002_0	7	3	20%	01	3-1;3-2;3-3;3-4;7a;7b;7c;7f;7i;7k;8a1;8b1;8b2;8b3;9a1;9a2;9b;9c;10a1;10a2;14d;16b;17a;17b;18a;		1	20	20	2			2				2	
H6154	001	0	1	02	01	H6154_001_0	6	1	Most Medicare-covered services	01	6;7a;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9d;11b;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	40	40	2			2				2	
H6154	001	0	1	02	01	H6154_001_0	6	2	10a1 Ground Ambulance Services	01	10a1;		2			1	265.00	265.00	2				2	
H6154	001	0	1	02	01	H6154_001_0	6	3	10a2 Air Ambulance Services	01	10a2;		1	20	20	2			2				2	
H6154	001	0	1	02	01	H6154_001_0	6	4	MC 11c: Diabetic Supplies and Services	01	11c;		1	0	40	2			2				2	
H6154	001	0	1	02	01	H6154_001_0	6	5	Part B Drug Min/Max coin & Insulin copay	01	15;		1	0	40	1	35.00	35.00	2				2	
H6306	013	0	1	02	01	H6306_013_0	7	1	POS Group = $0, 0%	11	6;7a;9d;14a;14d;14e1;14e2;14e3;14e4;14e5;	14b;14c7;	2			2			2				2	
H6306	013	0	1	02	01	H6306_013_0	7	10	POS Group = $265	01	10a1;10a2;		2			1	265.00	265.00	2				2	
H6306	013	0	1	02	01	H6306_013_0	7	11	POS Group = $3000	10		16a;16b;	1	0	50	1	35.00	35.00	1	3000.00	3		2	
H6306	013	0	1	02	01	H6306_013_0	7	12	POS Group = 0%-20%	01	15;		1	0	20	2			2				2	
H6306	013	0	1	02	01	H6306_013_0	7	13	POS Group = $55	01	7c;		2			1	55.00	55.00	2				2	
H6306	013	0	1	02	01	H6306_013_0	7	14	POS Group = $300	10		17b;	2			2			1	300.00	3		2	
H6306	013	0	1	02	01	H6306_013_0	7	2	POS Group = 20%	01	11a;11b;11c;12;17b;		1	20	20	2			2				2	
H6306	013	0	1	02	01	H6306_013_0	7	3	POS Group = 40%	01	8a1;8a2;8b1;8b2;		1	40	40	2			2				2	
H6306	013	0	1	02	01	H6306_013_0	7	4	POS Group = 30%	01	8b3;		1	30	30	2			2				2	
H6306	013	0	1	02	01	H6306_013_0	7	5	POS Group =  $50	01	3-1;3-3;3-4;5;7b;7d;7e;7f;7g;7h;7i;7k;9c;17a;18a;		2			1	50.00	50.00	2				2	
H6306	013	0	1	02	01	H6306_013_0	7	6	POS Group = $65	01	3-2;		2			1	65.00	65.00	2				2	
H6306	013	0	1	02	01	H6306_013_0	7	7	POS Group = $35	01	16b;		2			1	35.00	35.00	2				2	
H6306	013	0	1	02	01	H6306_013_0	7	8	POS Group = $450	01	9a1;9a2;		2			1	450.00	450.00	2				2	
H6306	013	0	1	02	01	H6306_013_0	7	9	POS Group = $350	01	9b;		2			1	350.00	350.00	2				2	
H6306	014	0	1	02	01	H6306_014_0	8	1	POS Group = $0, 0%	11	6;7a;9d;14a;14d;14e1;14e2;14e3;14e4;14e5;	14b;14c7;	2			2			2				2	
H6306	014	0	1	02	01	H6306_014_0	8	10	POS Group = $350	01	9a1;9a2;9b;		2			1	350.00	350.00	2				2	
H6306	014	0	1	02	01	H6306_014_0	8	11	POS Group = 20%	01	15;		1	20	20	2			2				2	
H6306	014	0	1	02	01	H6306_014_0	8	12	POS Group = $45	01	7c;		2			1	45.00	45.00	2				2	
H6306	014	0	1	02	01	H6306_014_0	8	13	POS Group = $300	10		17b;	2			2			1	300.00	3		2	
H6306	014	0	1	02	01	H6306_014_0	8	2	POS Group = 20%	01	11a;11b;11c;12;17b;		1	20	20	2			2				2	
H6306	014	0	1	02	01	H6306_014_0	8	3	POS Group = 30%	01	8b3;		1	30	30	2			2				2	
H6306	014	0	1	02	01	H6306_014_0	8	4	POS Group = $15	01	3-1;3-2;3-3;3-4;		2			1	15.00	15.00	2				2	
H6306	014	0	1	02	01	H6306_014_0	8	5	POS Group = $35	01	16b;		2			1	35.00	35.00	2				2	
H6306	014	0	1	02	01	H6306_014_0	8	6	POS Group = $40	01	5;7b;7d;7e;7f;7g;7h;7i;7k;9c;17a;18a;		2			1	40.00	40.00	2				2	
H6306	014	0	1	02	01	H6306_014_0	8	7	POS Group = 40%	01	8a1;8a2;8b1;8b2;		1	40	40	2			2				2	
H6306	014	0	1	02	01	H6306_014_0	8	8	POS Group = $3000	10		16a;16b;	1	0	50	1	35.00	35.00	1	3000.00	3		2	
H6306	014	0	1	02	01	H6306_014_0	8	9	POS Group = $265	01	10a1;10a2;		2			1	265.00	265.00	2				2	
H6306	015	0	1	02	01	H6306_015_0	6	1	POS Group 1 =30%	11	3-1;3-2;3-3;3-4;5;6;8b1;8b2;8b3;9a2;9c;	14b;	1	30	30	2			2				2	
H6306	015	0	1	02	01	H6306_015_0	6	2	POS Group 2= 20%	01	11a;11b;11c;12;17b;		1	20	20	2			2				2	
H6306	015	0	1	02	01	H6306_015_0	6	3	POS Group 6=$200	10		17b;	2			2			1	200.00	3		2	
H6306	015	0	1	02	01	H6306_015_0	6	4	POS Group 4 =$0, 0%	11	9d;14a;14d;14e1;14e2;14e3;14e4;14e5;17a;	14c7;17a;	2			2			2				2	
H6306	015	0	1	02	01	H6306_015_0	6	5	POS Group 5 =$65	01	7b;7c;7d;7e;7f;7g;7h;7i;7k;16b;18a;		2			1	65.00	65.00	2				2	
H6306	015	0	1	02	01	H6306_015_0	6	6	POS Group 6 = $1500	10		16a;16b;	1	0	40	2			1	1500.00	3		1	50.00
H6306	015	0	1	02	01	H6306_015_0	6	7	POS Group 7 = 0%-20%	01	15;		1	0	20	2			2				2	
H6306	015	0	1	02	01	H6306_015_0	6	8	POS Group 8 = $40	01	7a;8a1;8a2;		2			1	40.00	40.00	2				2	
H6306	015	0	1	02	01	H6306_015_0	6	9	POS Group 9=$400	01	9a1;9b;		2			1	400.00	400.00	2				2	
H6306	016	0	1	02	01	H6306_016_0	5	1	POS Group =  $0, 0%	11	6;7a;9d;14a;14d;14e1;14e2;14e3;14e4;14e5;	14b;14c7;	2			2			2				2	
H6306	016	0	1	02	01	H6306_016_0	5	10	POS Group = $265	01	10a1;10a2;		2			1	265.00	265.00	2				2	
H6306	016	0	1	02	01	H6306_016_0	5	11	POS Group = $3000	10		16a;16b;	2			2			1	3000.00	3		2	
H6306	016	0	1	02	01	H6306_016_0	5	12	POS Group = $55	01	7c;		2			1	55.00	55.00	2				2	
H6306	016	0	1	02	01	H6306_016_0	5	13	POS Group = $300	10		17b;	2			2			1	300.00	3		2	
H6306	016	0	1	02	01	H6306_016_0	5	2	POS Group = 20%	01	11a;11b;11c;12;15;17b;		1	20	20	2			2				2	
H6306	016	0	1	02	01	H6306_016_0	5	3	POS Group = 40%	01	8a1;8a2;8b1;8b2;		1	40	40	2			2				2	
H6306	016	0	1	02	01	H6306_016_0	5	4	POS Group = 30%	01	8b3;		1	30	30	2			2				2	
H6306	016	0	1	02	01	H6306_016_0	5	5	POS Group = $50	01	3-1;3-3;3-4;5;7b;7d;7e;7f;7g;7h;7i;7k;9c;17a;18a;		2			1	50.00	50.00	2				2	
H6306	016	0	1	02	01	H6306_016_0	5	6	POS Group = $65	01	3-2;		2			1	65.00	65.00	2				2	
H6306	016	0	1	02	01	H6306_016_0	5	7	POS Group = $35	01	16b;		2			1	35.00	35.00	2				2	
H6306	016	0	1	02	01	H6306_016_0	5	8	POS Group = $450	01	9a1;9a2;		2			1	450.00	450.00	2				2	
H6306	016	0	1	02	01	H6306_016_0	5	9	POS Group = $350	01	9b;		2			1	350.00	350.00	2				2	
H6306	017	0	1	02	01	H6306_017_0	7	1	POS Group 1=30%	01	3-1;3-2;3-3;3-4;5;6;8b1;8b2;8b3;9a2;9c;		1	30	30	2			2				2	
H6306	017	0	1	02	01	H6306_017_0	7	2	POS Group 2=20%	01	11a;11b;11c;12;17b;		1	20	20	2			2				2	
H6306	017	0	1	02	01	H6306_017_0	7	3	POS Group 3=$200	10		17b;	2			2			1	200.00	3		2	
H6306	017	0	1	02	01	H6306_017_0	7	4	POS Group 4=$0	11	9d;14a;14d;14e1;14e2;14e3;14e4;14e5;17a;	14b;14c7;17a;	2			2			2				2	
H6306	017	0	1	02	01	H6306_017_0	7	5	POS Group 5=$65	01	7b;7c;7d;7e;7f;7g;7h;7i;7k;16b;18a;		2			1	65.00	65.00	2				2	
H6306	017	0	1	02	01	H6306_017_0	7	6	POS Group 6 = $1500	10		16a;16b;	1	0	40	2			1	1500.00	3		1	50.00
H6306	017	0	1	02	01	H6306_017_0	7	7	POS Group 7 = $40	01	7a;8a1;8a2;		2			1	40.00	40.00	2				2	
H6306	017	0	1	02	01	H6306_017_0	7	8	POS Group 8 = $400	01	9a1;9b;		2			1	400.00	400.00	2				2	
H6306	017	0	1	02	01	H6306_017_0	7	9	POS Group 9 = 0%-20%	01	15;		1	0	20	2			2				2	
H6306	018	0	1	02	01	H6306_018_0	8	1	POS Group 1 =30%	01	3-1;3-2;3-3;3-4;5;6;8b1;8b2;8b3;9a2;9c;		1	30	30	2			2				2	
H6306	018	0	1	02	01	H6306_018_0	8	10	POS Group 10 = $350	01	10a1;		2			1	350.00	350.00	2				2	
H6306	018	0	1	02	01	H6306_018_0	8	2	POS Group 2= 20%	01	11a;11b;11c;12;17b;		1	20	20	2			2				2	
H6306	018	0	1	02	01	H6306_018_0	8	3	POS Group 3 = $200	10		17b;	2			2			1	200.00	3		2	
H6306	018	0	1	02	01	H6306_018_0	8	4	POS Group 4 =$0	11	9d;14a;14d;14e1;14e2;14e3;14e4;14e5;17a;	14b;14c7;17a;	2			2			2				2	
H6306	018	0	1	02	01	H6306_018_0	8	5	POS Group 5 =$65	01	7b;7c;7d;7e;7f;7g;7h;7i;7k;16b;18a;		2			1	65.00	65.00	2				2	
H6306	018	0	1	02	01	H6306_018_0	8	6	POS Group 6 = $1500	10		16a;16b;	1	0	40	2			1	1500.00	3		1	50.00
H6306	018	0	1	02	01	H6306_018_0	8	7	POS Group 7 = $40	01	7a;8a1;8a2;		2			1	40.00	40.00	2				2	
H6306	018	0	1	02	01	H6306_018_0	8	8	POS Group 8 = $450	01	9a1;9b;10a2;		2			1	450.00	450.00	2				2	
H6306	018	0	1	02	01	H6306_018_0	8	9	POS Group 9 = 0%-20%	01	15;		1	0	20	2			2				2	
H6306	801	0	1	02	01	H6306_801_0	3	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H6306	801	0	1	02	01	H6306_801_0	3	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H6306	802	0	1	02	01	H6306_802_0	3	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H6306	802	0	1	02	01	H6306_802_0	3	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H6306	803	0	1	02	01	H6306_803_0	3	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H6306	803	0	1	02	01	H6306_803_0	3	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H6322	003	1	1	02	01	H6322_003_1	7	1	POS 1	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	14b;	1	20	20	2			2				2	
H6322	003	1	1	02	01	H6322_003_1	7	2	POS 2	01	15;		1	0	20	1	0.00	35.00	2				2	
H6322	003	2	1	02	01	H6322_003_2	7	1	POS 1	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;14b;	1	30	30	2			2				2	
H6322	003	2	1	02	01	H6322_003_2	7	2	POS 2	01	12;		1	20	30	2			2				2	
H6322	003	2	1	02	01	H6322_003_2	7	3	POS 3	01	15;		1	0	30	1	0.00	35.00	2				2	
H6453	011	0	1	02	01	H6453_011_0	6	1	50% coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;14b;	1	50	50	2			2				2	
H6453	011	0	1	02	01	H6453_011_0	6	10	Ground Ambulance	01	10a1;		2			1	250.00	250.00	2				2	
H6453	011	0	1	02	01	H6453_011_0	6	2	Non-Medicare Dental	10		16a;16b;	2			2			1	2000.00	3		2	
H6453	011	0	1	02	01	H6453_011_0	6	3	Non-Medicare Eye Exams	10		17a;	1	50	50	2			2				2	
H6453	011	0	1	02	01	H6453_011_0	6	4	Air Ambulance	01	10a2;		2			1	300.00	300.00	2				2	
H6453	011	0	1	02	01	H6453_011_0	6	5	Non-Medicare Hearing Exams	10		18a;	2			2			2				2	
H6453	011	0	1	02	01	H6453_011_0	6	6	ESRD	01	12;		1	20	20	2			2				2	
H6453	011	0	1	02	01	H6453_011_0	6	7	Non-Medicare Eye Wear	10		17b;	2			2			1	400.00	3		2	
H6453	011	0	1	02	01	H6453_011_0	6	8	Hearing Aids	10		18a2;18b;	2			2			1	1100.00	3		2	
H6453	011	0	1	02	01	H6453_011_0	6	9	Part B Rx	01	15;		1	0	50	1	35.00	35.00	2				2	
H6453	013	1	1	02	01	H6453_013_1	7	1	50% coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;14b;	1	50	50	2			2				2	
H6453	013	1	1	02	01	H6453_013_1	7	10	Ground Ambulance	01	10a1;		2			1	250.00	250.00	2				2	
H6453	013	1	1	02	01	H6453_013_1	7	2	Non-Medicare Dental	10		16a;16b;	2			2			1	2000.00	3		2	
H6453	013	1	1	02	01	H6453_013_1	7	3	Non-Medicare Eye Exams	10		17a;	1	50	50	2			2				2	
H6453	013	1	1	02	01	H6453_013_1	7	4	Air Ambulance	01	10a2;		2			1	260.00	260.00	2				2	
H6453	013	1	1	02	01	H6453_013_1	7	5	Non-Medicare Hearing Exams	10		18a;	2			2			2				2	
H6453	013	1	1	02	01	H6453_013_1	7	6	ESRD	01	12;		1	20	20	2			2				2	
H6453	013	1	1	02	01	H6453_013_1	7	7	Non-Medicare Eye Wear	10		17b;	2			2			1	400.00	3		2	
H6453	013	1	1	02	01	H6453_013_1	7	8	Hearing Aids	10		18a2;18b;	2			2			1	1100.00	3		2	
H6453	013	1	1	02	01	H6453_013_1	7	9	Part B Rx	01	15;		1	0	50	1	35.00	35.00	2				2	
H6453	013	2	1	02	01	H6453_013_2	7	1	50% coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;14b;	1	50	50	2			2				2	
H6453	013	2	1	02	01	H6453_013_2	7	10	Ground Ambulance	01	10a1;		2			1	250.00	250.00	2				2	
H6453	013	2	1	02	01	H6453_013_2	7	2	Non-Medicare Dental	10		16a;16b;	2			2			1	2000.00	3		2	
H6453	013	2	1	02	01	H6453_013_2	7	3	Non-Medicare Eye Exams	10		17a;	1	50	50	2			2				2	
H6453	013	2	1	02	01	H6453_013_2	7	4	Air Ambulance	01	10a2;		2			1	260.00	260.00	2				2	
H6453	013	2	1	02	01	H6453_013_2	7	5	Non-Medicare Hearing Exams	10		18a;	2			2			2				2	
H6453	013	2	1	02	01	H6453_013_2	7	6	ESRD	01	12;		1	20	20	2			2				2	
H6453	013	2	1	02	01	H6453_013_2	7	7	Non-Medicare Eye Wear	10		17b;	2			2			1	400.00	3		2	
H6453	013	2	1	02	01	H6453_013_2	7	8	Hearing Aids	10		18a2;18b;	2			2			1	1100.00	3		2	
H6453	013	2	1	02	01	H6453_013_2	7	9	Part B Rx	01	15;		1	0	50	1	35.00	35.00	2				2	
H6453	013	3	1	02	01	H6453_013_3	7	1	50% coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;14b;	1	50	50	2			2				2	
H6453	013	3	1	02	01	H6453_013_3	7	10	Ground Ambulance	01	10a1;		2			1	250.00	250.00	2				2	
H6453	013	3	1	02	01	H6453_013_3	7	2	Non-Medicare Dental	10		16a;16b;	2			2			1	2000.00	3		2	
H6453	013	3	1	02	01	H6453_013_3	7	3	Non-Medicare Eye Exams	10		17a;	1	50	50	2			2				2	
H6453	013	3	1	02	01	H6453_013_3	7	4	Air Ambulance	01	10a2;		2			1	260.00	260.00	2				2	
H6453	013	3	1	02	01	H6453_013_3	7	5	Non-Medicare Hearing Exams	10		18a;	2			2			2				2	
H6453	013	3	1	02	01	H6453_013_3	7	6	ESRD	01	12;		1	20	20	2			2				2	
H6453	013	3	1	02	01	H6453_013_3	7	7	Non-Medicare Eye Wear	10		17b;	2			2			1	400.00	3		2	
H6453	013	3	1	02	01	H6453_013_3	7	8	Hearing Aids	10		18a2;18b;	2			2			1	1100.00	3		2	
H6453	013	3	1	02	01	H6453_013_3	7	9	Part B Rx	01	15;		1	0	50	1	35.00	35.00	2				2	
H6453	013	4	1	02	01	H6453_013_4	7	1	50% coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;14b;	1	50	50	2			2				2	
H6453	013	4	1	02	01	H6453_013_4	7	10	Ground Ambulance	01	10a1;		2			1	250.00	250.00	2				2	
H6453	013	4	1	02	01	H6453_013_4	7	2	Non-Medicare Dental	10		16a;16b;	2			2			1	2000.00	3		2	
H6453	013	4	1	02	01	H6453_013_4	7	3	Non-Medicare Eye Exams	10		17a;	1	50	50	2			2				2	
H6453	013	4	1	02	01	H6453_013_4	7	4	Air Ambulance	01	10a2;		2			1	260.00	260.00	2				2	
H6453	013	4	1	02	01	H6453_013_4	7	5	Non-Medicare Hearing Exams	10		18a;	2			2			2				2	
H6453	013	4	1	02	01	H6453_013_4	7	6	ESRD	01	12;		1	20	20	2			2				2	
H6453	013	4	1	02	01	H6453_013_4	7	7	Non-Medicare Eye Wear	10		17b;	2			2			1	400.00	3		2	
H6453	013	4	1	02	01	H6453_013_4	7	8	Hearing Aids	10		18a2;18b;	2			2			1	1100.00	3		2	
H6453	013	4	1	02	01	H6453_013_4	7	9	Part B Rx	01	15;		1	0	50	1	35.00	35.00	2				2	
H6453	013	5	1	02	01	H6453_013_5	7	1	50% coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;14b;	1	50	50	2			2				2	
H6453	013	5	1	02	01	H6453_013_5	7	10	Ground Ambulance	01	10a1;		2			1	250.00	250.00	2				2	
H6453	013	5	1	02	01	H6453_013_5	7	2	Non-Medicare Dental	10		16a;16b;	2			2			1	2000.00	3		2	
H6453	013	5	1	02	01	H6453_013_5	7	3	Non-Medicare Eye Exams	10		17a;	1	50	50	2			2				2	
H6453	013	5	1	02	01	H6453_013_5	7	4	Air Ambulance	01	10a2;		2			1	260.00	260.00	2				2	
H6453	013	5	1	02	01	H6453_013_5	7	5	Non-Medicare Hearing Exams	10		18a;	2			2			2				2	
H6453	013	5	1	02	01	H6453_013_5	7	6	ESRD	01	12;		1	20	20	2			2				2	
H6453	013	5	1	02	01	H6453_013_5	7	7	Non-Medicare Eye Wear	10		17b;	2			2			1	400.00	3		2	
H6453	013	5	1	02	01	H6453_013_5	7	8	Hearing Aids	10		18a2;18b;	2			2			1	1100.00	3		2	
H6453	013	5	1	02	01	H6453_013_5	7	9	Part B Rx	01	15;		1	0	50	1	35.00	35.00	2				2	
H6453	017	1	1	02	01	H6453_017_1	7	1	50% coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;14b;	1	50	50	2			2				2	
H6453	017	1	1	02	01	H6453_017_1	7	10	Ground Ambulance	01	10a1;		2			1	250.00	250.00	2				2	
H6453	017	1	1	02	01	H6453_017_1	7	2	Non-Medicare Dental	10		16a;16b;	2			2			1	2200.00	3		2	
H6453	017	1	1	02	01	H6453_017_1	7	3	Non-Medicare Eye Exams	10		17a;	1	50	50	2			2				2	
H6453	017	1	1	02	01	H6453_017_1	7	4	Air Ambulance	01	10a2;		2			1	260.00	260.00	2				2	
H6453	017	1	1	02	01	H6453_017_1	7	5	Non-Medicare Hearing Exams	10		18a;	2			2			2				2	
H6453	017	1	1	02	01	H6453_017_1	7	6	ESRD	01	12;		1	20	20	2			2				2	
H6453	017	1	1	02	01	H6453_017_1	7	7	Non-Medicare Eye Wear	10		17b;	2			2			1	450.00	3		2	
H6453	017	1	1	02	01	H6453_017_1	7	8	Hearing Aids	10		18a2;18b;	2			2			1	1100.00	3		2	
H6453	017	1	1	02	01	H6453_017_1	7	9	Part B Rx	01	15;		1	0	50	1	35.00	35.00	2				2	
H6453	017	2	1	02	01	H6453_017_2	7	1	50% coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;14b;	1	50	50	2			2				2	
H6453	017	2	1	02	01	H6453_017_2	7	10	Ground Ambulance	01	10a1;		2			1	250.00	250.00	2				2	
H6453	017	2	1	02	01	H6453_017_2	7	2	Non-Medicare Dental	10		16a;16b;	2			2			1	2200.00	3		2	
H6453	017	2	1	02	01	H6453_017_2	7	3	Non-Medicare Eye Exams	10		17a;	1	50	50	2			2				2	
H6453	017	2	1	02	01	H6453_017_2	7	4	Air Ambulance	01	10a2;		2			1	260.00	260.00	2				2	
H6453	017	2	1	02	01	H6453_017_2	7	5	Non-Medicare Hearing Exams	10		18a;	2			2			2				2	
H6453	017	2	1	02	01	H6453_017_2	7	6	ESRD	01	12;		1	20	20	2			2				2	
H6453	017	2	1	02	01	H6453_017_2	7	7	Non-Medicare Eye Wear	10		17b;	2			2			1	450.00	3		2	
H6453	017	2	1	02	01	H6453_017_2	7	8	Hearing Aids	10		18a2;18b;	2			2			1	1100.00	3		2	
H6453	017	2	1	02	01	H6453_017_2	7	9	Part B Rx	01	15;		1	0	50	1	35.00	35.00	2				2	
H6453	018	1	1	02	01	H6453_018_1	9	1	50% coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;14b;	1	50	50	2			2				2	
H6453	018	1	1	02	01	H6453_018_1	9	10	Ground Ambulance	01	10a1;		2			1	250.00	250.00	2				2	
H6453	018	1	1	02	01	H6453_018_1	9	2	Non-Medicare Dental	10		16a;16b;	2			2			1	2500.00	3		2	
H6453	018	1	1	02	01	H6453_018_1	9	3	Non-Medicare Eye Exams	10		17a;	1	50	50	2			2				2	
H6453	018	1	1	02	01	H6453_018_1	9	4	Air Ambulance	01	10a2;		2			1	260.00	260.00	2				2	
H6453	018	1	1	02	01	H6453_018_1	9	5	Non-Medicare Hearing Exams	10		18a;	2			2			2				2	
H6453	018	1	1	02	01	H6453_018_1	9	6	ESRD	01	12;		1	20	20	2			2				2	
H6453	018	1	1	02	01	H6453_018_1	9	7	Non-Medicare Eye Wear	10		17b;	2			2			1	350.00	3		2	
H6453	018	1	1	02	01	H6453_018_1	9	8	Hearing Aids	10		18a2;18b;	2			2			1	1100.00	3		2	
H6453	018	1	1	02	01	H6453_018_1	9	9	Part B Rx	01	15;		1	0	50	1	35.00	35.00	2				2	
H6453	018	2	1	02	01	H6453_018_2	9	1	50% coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;14b;	1	50	50	2			2				2	
H6453	018	2	1	02	01	H6453_018_2	9	10	Ground Ambulance	01	10a1;		2			1	250.00	250.00	2				2	
H6453	018	2	1	02	01	H6453_018_2	9	2	Non-Medicare Dental	10		16a;16b;	2			2			1	2500.00	3		2	
H6453	018	2	1	02	01	H6453_018_2	9	3	Non-Medicare Eye Exams	10		17a;	1	50	50	2			2				2	
H6453	018	2	1	02	01	H6453_018_2	9	4	Air Ambulance	01	10a2;		2			1	260.00	260.00	2				2	
H6453	018	2	1	02	01	H6453_018_2	9	5	Non-Medicare Hearing Exams	10		18a;	2			2			2				2	
H6453	018	2	1	02	01	H6453_018_2	9	6	ESRD	01	12;		1	20	20	2			2				2	
H6453	018	2	1	02	01	H6453_018_2	9	7	Non-Medicare Eye Wear	10		17b;	2			2			1	300.00	3		2	
H6453	018	2	1	02	01	H6453_018_2	9	8	Hearing Aids	10		18a2;18b;	2			2			1	1100.00	3		2	
H6453	018	2	1	02	01	H6453_018_2	9	9	Part B Rx	01	15;		1	0	50	1	35.00	35.00	2				2	
H6453	019	0	1	02	01	H6453_019_0	8	1	50% coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;14b;	1	50	50	2			2				2	
H6453	019	0	1	02	01	H6453_019_0	8	10	Ground Ambulance	01	10a1;		1	50	50	2			2				2	
H6453	019	0	1	02	01	H6453_019_0	8	2	Non-Medicare Dental	10		16a;16b;	2			2			1	3800.00	3		2	
H6453	019	0	1	02	01	H6453_019_0	8	3	Non-Medicare Eye Exams	10		17a;	1	50	50	2			2				2	
H6453	019	0	1	02	01	H6453_019_0	8	4	Air Ambulance	01	10a2;		1	50	50	2			2				2	
H6453	019	0	1	02	01	H6453_019_0	8	5	Non-Medicare Hearing Exams	10		18a;	2			2			2				2	
H6453	019	0	1	02	01	H6453_019_0	8	6	ESRD	01	12;		1	20	20	2			2				2	
H6453	019	0	1	02	01	H6453_019_0	8	7	Non-Medicare Eye Wear	10		17b;	2			2			1	300.00	3		2	
H6453	019	0	1	02	01	H6453_019_0	8	8	Hearing Aids	10		18a2;18b;	2			2			1	1500.00	3		2	
H6453	019	0	1	02	01	H6453_019_0	8	9	Part B Rx	01	15;		1	0	50	1	35.00	35.00	2				2	
H6453	804	0	1	02	01	H6453_804_0	4	1	Part B Rx	01	6;15;		1	0	50	1	35.00	35.00	2				2	
H6453	804	0	1	02	01	H6453_804_0	4	2	Medicare-covered	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	50	50	2			2				2	
H6526	001	0	1	02	01	H6526_001_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H6526	001	0	1	02	01	H6526_001_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H6526	002	0	1	02	01	H6526_002_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H6595	003	0	1	02	01	H6595_003_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H6595	003	0	1	02	01	H6595_003_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H6595	004	0	1	02	01	H6595_004_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H6622	010	0	1	02	01	H6622_010_0	5	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	1000.00	3		2	
H6622	013	0	1	02	01	H6622_013_0	5	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	2000.00	3		2	
H6622	014	0	1	02	01	H6622_014_0	5	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	2000.00	3		2	
H6622	021	1	1	02	01	H6622_021_1	5	1	Point of Service Group 1	10		16a;	2			2			1	1000.00	3		2	
H6622	021	1	1	02	01	H6622_021_1	5	2	Point of Service Group 2	10		16b;	1	0	50	1	25.00	25.00	1	1000.00	3		2	
H6622	021	2	1	02	01	H6622_021_2	5	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	2000.00	3		2	
H6622	022	0	1	02	01	H6622_022_0	5	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	2000.00	3		2	
H6622	023	0	1	02	01	H6622_023_0	5	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	4000.00	3		2	
H6622	025	0	1	02	01	H6622_025_0	6	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	1500.00	3		2	
H6622	026	0	1	02	01	H6622_026_0	6	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	2000.00	3		2	
H6622	027	0	1	02	01	H6622_027_0	8	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	2000.00	3		2	
H6622	057	0	1	02	01	H6622_057_0	5	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	1500.00	3		2	
H6622	060	0	1	02	01	H6622_060_0	5	1	POS Group 1				2			1	0.00	0.00	1	1500.00	3		2	
H6622	061	0	1	02	01	H6622_061_0	5	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	1500.00	3		2	
H6622	073	0	1	02	01	H6622_073_0	5	1	Point of Service Group 1	11	16b;	16a;16b;	2			1	0.00	0.00	2				2	
H6622	088	0	1	02	01	H6622_088_0	7	1	Point of Service Group 1	11	6;7a;7c;7i;8a2;9d;14a;14d;14e1;14e2;14e3;14e4;14e5;17b;	9d_2;14b;17a;17b;	2			1	0.00	0.00	2				2	
H6622	088	0	1	02	01	H6622_088_0	7	2	Point of Service Group 2	10		16a;16b;	2			1	0.00	0.00	1	3000.00	3		2	
H6622	088	0	1	02	01	H6622_088_0	7	3	Point of Service Group 3	01	9a2;		2			1	569.00	569.00	2				2	
H6622	088	0	1	02	01	H6622_088_0	7	4	Point of Service Group 4	01	11c;		1	10	20	1	0.00	0.00	2				2	
H6622	088	0	1	02	01	H6622_088_0	7	5	Point of Service Group 5	11	3-1;3-2;3-3;3-4;5;7b;7d;7e;7f;7h;7k;8b1;8b2;9a1;9b;9c;10a1;10a2;11a;11b;12;16b;18a;	7f_2;13a;	1	20	20	2			2				2	
H6622	088	0	1	02	01	H6622_088_0	7	6	Point of Service Group 6	01	7g;15;17a;		1	20	20	1	0.00	0.00	2				2	
H6622	088	0	1	02	01	H6622_088_0	7	7	Point of Service Group 7	01	8a1;8b3;		1	20	20	1	0.00	55.00	2				2	
H6622	088	0	1	02	01	H6622_088_0	7	8	Point of Service Group 8	10		18a;18a2;18b;	1	50	50	2			2				2	
H6706	001	0	1	02	01	H6706_001_0	6	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H6706	001	0	1	02	01	H6706_001_0	6	2	Group 2	10		16b;	1	0	50	2			2				2	
H6750	014	0	1	02	01	H6750_014_0	7	1	Primary Care Provider	01	7a;		2			1	35.00	35.00	2				2	
H6750	014	0	1	02	01	H6750_014_0	7	2	40% Coinsurance	11	3-1;3-2;3-3;3-4;5;6;7b;7c;7i;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9d;11a;11b;12;14a;14d;14e2;14e3;14e4;14e5;	9d_2;14b;	1	40	40	2			2				2	
H6750	014	0	1	02	01	H6750_014_0	7	3	Other Health Care Professional	01	7g;		1	40	40	1	35.00	65.00	2				2	
H6750	014	0	1	02	01	H6750_014_0	7	4	$65 Copayment	11	7d;7e;7f;7h;7k;9c;14e1;16b;17a;17b;18a;	17a;	2			1	65.00	65.00	2				2	
H6750	014	0	1	02	01	H6750_014_0	7	5	$300 Copayment	01	10a1;10a2;		2			1	300.00	300.00	2				2	
H6750	014	0	1	02	01	H6750_014_0	7	6	$0 Copayment				2			1	0.00	0.00	2				2	
H6750	014	0	1	02	01	H6750_014_0	7	7	Part B Drugs	01	15;		1	40	40	1	35.00	35.00	2				2	
H6750	014	0	1	02	01	H6750_014_0	7	8	Diabetic Supplies and Services	01	11c;		1	40	40	1	0.00	0.00	2				2	
H6750	811	0	1	02	01	H6750_811_0	1	1	40% Coinsurance	01	3-1;3-2;3-3;3-4;5;6;7b;7c;7i;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9d;11a;11b;12;14a;14d;14e2;14e3;14e4;14e5;		1	40	40	2			2				2	
H6750	811	0	1	02	01	H6750_811_0	1	2	Professional Services	01	7a;7d;7e;7f;7g;7h;7k;9c;14e1;16b;17a;17b;18a;		1	40	40	1	35.00	65.00	2				2	
H6750	811	0	1	02	01	H6750_811_0	1	3	Ambulance	01	10a1;10a2;		2			1	300.00	300.00	2				2	
H6750	811	0	1	02	01	H6750_811_0	1	4	Medicare Part B Rx Drugs	01	15;		1	40	40	1	35.00	35.00	2				2	
H6750	811	0	1	02	01	H6750_811_0	1	5	Diabetes Supplies and Services	01	11c;		1	0	40	2			2				2	
H6750	812	0	1	02	01	H6750_812_0	1	1	40% Coinsurance	01	3-1;3-2;3-3;3-4;5;6;7b;7c;7i;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9d;11a;11b;12;14a;14d;14e2;14e3;14e4;14e5;		1	40	40	2			2				2	
H6750	812	0	1	02	01	H6750_812_0	1	2	Professional Services	01	7a;7d;7e;7f;7g;7h;7k;9c;14e1;16b;17a;17b;18a;		1	40	40	1	35.00	65.00	2				2	
H6750	812	0	1	02	01	H6750_812_0	1	3	Ambulance	01	10a1;10a2;		2			1	300.00	300.00	2				2	
H6750	812	0	1	02	01	H6750_812_0	1	4	Medicare Part B Rx Drugs	01	15;		1	40	40	1	35.00	35.00	2				2	
H6750	812	0	1	02	01	H6750_812_0	1	5	Diabetes Supplies and Services	01	11c;		1	0	40	2			2				2	
H6750	813	0	1	02	01	H6750_813_0	1	1	40% Coinsurance	01	3-1;3-2;3-3;3-4;5;6;7b;7c;7i;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9d;11a;11b;12;14a;14d;14e2;14e3;14e4;14e5;		1	40	40	2			2				2	
H6750	813	0	1	02	01	H6750_813_0	1	2	Professional Services	01	7a;7d;7e;7f;7g;7h;7k;9c;14e1;16b;17a;17b;18a;		1	40	40	1	35.00	65.00	2				2	
H6750	813	0	1	02	01	H6750_813_0	1	3	Ambulance	01	10a1;10a2;		2			1	300.00	300.00	2				2	
H6750	813	0	1	02	01	H6750_813_0	1	4	Medicare Part B Rx Drugs	01	15;		1	40	40	1	35.00	35.00	2				2	
H6750	813	0	1	02	01	H6750_813_0	1	5	Diabetes Supplies and Services	01	11c;		1	0	40	2			2				2	
H6750	814	0	1	02	01	H6750_814_0	1	1	40% Coinsurance	01	3-1;3-2;3-3;3-4;5;6;7b;7c;7i;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9d;11a;11b;12;14a;14d;14e2;14e3;14e4;14e5;		1	40	40	2			2				2	
H6750	814	0	1	02	01	H6750_814_0	1	2	Professional Services	01	7a;7d;7e;7f;7g;7h;7k;9c;14e1;16b;17a;17b;18a;		1	40	40	1	35.00	65.00	2				2	
H6750	814	0	1	02	01	H6750_814_0	1	3	Ambulance	01	10a1;10a2;		2			1	300.00	300.00	2				2	
H6750	814	0	1	02	01	H6750_814_0	1	4	Medicare Part B Rx Drugs	01	15;		1	40	40	1	35.00	35.00	2				2	
H6750	814	0	1	02	01	H6750_814_0	1	5	Diabetes Supplies and Services	01	11c;		1	0	40	2			2				2	
H6832	003	0	1	02	01	H6832_003_0	8	1	$0 Copay Group	01	7a;8a2;		2			2			2				2	
H6832	003	0	1	02	01	H6832_003_0	8	2	$100 Copay Group	01	9a2;		2			1	100.00	100.00	2				2	
H6832	003	0	1	02	01	H6832_003_0	8	3	20% Coinsurance Group	01	7d;8a1;8b1;8b2;8b3;9a1;9b;		1	20	20	2			2				2	
H6847	001	0	1	02	01	H6847_001_0	11	1	$0	11	3-1;3-2;3-3;3-4;9d;14a;14d;14e1;14e2;14e3;14e4;14e5;	9d_2;	2			2			2				2	
H6847	001	0	1	02	01	H6847_001_0	11	10	NM Preventive Dental	10		16a;	2			2			2				2	
H6847	001	0	1	02	01	H6847_001_0	11	11	Fitness Reimbursement	10		14c4;	2			2			1	300.00	3		2	
H6847	001	0	1	02	01	H6847_001_0	11	12	Weight Management Reimbursement	10		14c16;	2			2			1	150.00	3		2	
H6847	001	0	1	02	01	H6847_001_0	11	13	Other health care professionals OON	01	7g;		2			1	20.00	50.00	2				2	
H6847	001	0	1	02	01	H6847_001_0	11	2	$20	11	7a;	14b;	2			1	20.00	20.00	2				2	
H6847	001	0	1	02	01	H6847_001_0	11	3	$50	01	7b;7c;7d;7e;7f;7h;7i;7k;9c;16b;17a;17b;18a;		2			1	50.00	50.00	2				2	
H6847	001	0	1	02	01	H6847_001_0	11	4	$200	01	10a1;10a2;		2			1	200.00	200.00	2				2	
H6847	001	0	1	02	01	H6847_001_0	11	5	20%	01	8a1;8a2;8b1;8b2;8b3;11a;11b;11c;12;15;		1	20	20	2			2				2	
H6847	001	0	1	02	01	H6847_001_0	11	6	30%	01	5;6;9a1;9a2;9b;		1	30	30	2			2				2	
H6847	001	0	1	02	01	H6847_001_0	11	7	NM Eyewear	10		17b;	2			2			1	250.00	3		2	
H6847	001	0	1	02	01	H6847_001_0	11	8	Routine Vision	10		17a;	2			2			1	40.00	3		2	
H6847	001	0	1	02	01	H6847_001_0	11	9	NM Comprehensive Dental	10		16b;	1	20	20	2			2				2	
H6847	801	0	1	02	01	H6847_801_0	7	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H6847	801	0	1	02	01	H6847_801_0	7	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H7147	001	0	1	02	01	H7147_001_0	11	1	Supplemental Benefit - Dental	10		16a;16b;	1	0	20	2			2				2	
H7147	003	0	1	02	01	H7147_003_0	12	1	Supplemental Benefit - Dental	10		16a;16b;	1	0	20	2			2				2	
H7147	004	0	1	02	01	H7147_004_0	11	1	Supplemental Benefit - Dental	10		16a;16b;	1	0	20	2			2				2	
H7147	005	0	1	02	01	H7147_005_0	10	1	Supplemental Benefit - Dental	10		16a;16b;	1	0	20	2			2				2	
H7147	007	0	1	02	01	H7147_007_0	12	1	Supplemental Benefit - Dental	10		16a;16b;	1	0	20	2			2				2	
H7149	001	0	1	02	01	H7149_001_0	7	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H7149	007	0	1	02	01	H7149_007_0	4	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H7149	008	0	1	02	01	H7149_008_0	7	1	50% coinsurance	10		16a;16b;	1	50	50	2			2				2	
H7149	009	0	1	02	01	H7149_009_0	7	1	$0 copay	10		16a;16b;	2			1	0.00	0.00	2				2	
H7163	002	0	1	02	01	H7163_002_0	6	1	50% coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;14b;	1	50	50	2			2				2	
H7163	002	0	1	02	01	H7163_002_0	6	10	Ground Ambulance	01	10a1;		2			1	250.00	250.00	2				2	
H7163	002	0	1	02	01	H7163_002_0	6	2	Non-Medicare Dental	10		16a;16b;	2			2			1	2000.00	3		2	
H7163	002	0	1	02	01	H7163_002_0	6	3	Non-Medicare Eye Exams	10		17a;	1	50	50	2			2				2	
H7163	002	0	1	02	01	H7163_002_0	6	4	Air Ambulance	01	10a2;		2			1	260.00	260.00	2				2	
H7163	002	0	1	02	01	H7163_002_0	6	5	Non-Medicare Hearing Exams	10		18a;	2			2			2				2	
H7163	002	0	1	02	01	H7163_002_0	6	6	ESRD	01	12;		1	20	20	2			2				2	
H7163	002	0	1	02	01	H7163_002_0	6	7	Non-Medicare Eye Wear	10		17b;	2			2			1	500.00	3		2	
H7163	002	0	1	02	01	H7163_002_0	6	8	Hearing Aids	10		18a2;18b;	2			2			1	1100.00	3		2	
H7163	002	0	1	02	01	H7163_002_0	6	9	Part B Rx	01	15;		1	0	50	1	35.00	35.00	2				2	
H7163	003	0	1	02	01	H7163_003_0	8	1	50% coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;14b;	1	50	50	2			2				2	
H7163	003	0	1	02	01	H7163_003_0	8	10	Ground Ambulance	01	10a1;		1	50	50	2			2				2	
H7163	003	0	1	02	01	H7163_003_0	8	2	Non-Medicare Dental	10		16a;16b;	2			2			1	3800.00	3		2	
H7163	003	0	1	02	01	H7163_003_0	8	3	Non-Medicare Eye Exams	10		17a;	1	50	50	2			2				2	
H7163	003	0	1	02	01	H7163_003_0	8	4	Air Ambulance	01	10a2;		1	50	50	2			2				2	
H7163	003	0	1	02	01	H7163_003_0	8	5	Non-Medicare Hearing Exams	10		18a;	2			2			2				2	
H7163	003	0	1	02	01	H7163_003_0	8	6	ESRD	01	12;		1	20	20	2			2				2	
H7163	003	0	1	02	01	H7163_003_0	8	7	Non-Medicare Eye Wear	10		17b;	2			2			1	300.00	3		2	
H7163	003	0	1	02	01	H7163_003_0	8	8	Hearing Aids	10		18a2;18b;	2			2			1	1500.00	3		2	
H7163	003	0	1	02	01	H7163_003_0	8	9	Part B Rx	01	15;		1	0	50	1	35.00	35.00	2				2	
H7163	004	0	1	02	01	H7163_004_0	6	1	50% coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;14b;	1	50	50	2			2				2	
H7163	004	0	1	02	01	H7163_004_0	6	10	Ground Ambulance	01	10a1;		2			1	250.00	250.00	2				2	
H7163	004	0	1	02	01	H7163_004_0	6	2	Non-Medicare Dental	10		16a;16b;	2			2			1	2200.00	3		2	
H7163	004	0	1	02	01	H7163_004_0	6	3	Non-Medicare Eye Exams	10		17a;	1	50	50	2			2				2	
H7163	004	0	1	02	01	H7163_004_0	6	4	Air Ambulance	01	10a2;		2			1	260.00	260.00	2				2	
H7163	004	0	1	02	01	H7163_004_0	6	5	Non-Medicare Hearing Exams	10		18a;	2			2			2				2	
H7163	004	0	1	02	01	H7163_004_0	6	6	ESRD	01	12;		1	20	20	2			2				2	
H7163	004	0	1	02	01	H7163_004_0	6	7	Non-Medicare Eye Wear	10		17b;	2			2			1	500.00	3		2	
H7163	004	0	1	02	01	H7163_004_0	6	8	Hearing Aids	10		18a2;18b;	2			2			1	1100.00	3		2	
H7163	004	0	1	02	01	H7163_004_0	6	9	Part B Rx	01	15;		1	0	50	1	35.00	35.00	2				2	
H7163	005	0	1	02	01	H7163_005_0	6	1	50% coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;14b;	1	50	50	2			2				2	
H7163	005	0	1	02	01	H7163_005_0	6	10	Ground Ambulance	01	10a1;		2			1	250.00	250.00	2				2	
H7163	005	0	1	02	01	H7163_005_0	6	2	Non-Medicare Dental	10		16a;16b;	2			2			1	2000.00	3		2	
H7163	005	0	1	02	01	H7163_005_0	6	3	Non-Medicare Eye Exams	10		17a;	1	50	50	2			2				2	
H7163	005	0	1	02	01	H7163_005_0	6	4	Air Ambulance	01	10a2;		2			1	300.00	300.00	2				2	
H7163	005	0	1	02	01	H7163_005_0	6	5	Non-Medicare Hearing Exams	10		18a;	2			2			2				2	
H7163	005	0	1	02	01	H7163_005_0	6	6	ESRD	01	12;		1	20	20	2			2				2	
H7163	005	0	1	02	01	H7163_005_0	6	7	Non-Medicare Eye Wear	10		17b;	2			2			1	500.00	3		2	
H7163	005	0	1	02	01	H7163_005_0	6	8	Hearing Aids	10		18a2;18b;	2			2			1	1100.00	3		2	
H7163	005	0	1	02	01	H7163_005_0	6	9	Part B Rx	01	15;		1	0	50	1	35.00	35.00	2				2	
H7163	801	0	1	02	01	H7163_801_0	4	1	Part B Rx	01	6;15;		1	0	50	1	35.00	35.00	2				2	
H7163	801	0	1	02	01	H7163_801_0	4	2	Medicare-covered	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	50	50	2			2				2	
H7220	004	0	1	02	01	H7220_004_0	4	1	50% Coinsurance	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;15;16b;17a;17b;18a;		1	50	50	2			2				2	
H7220	004	0	1	02	01	H7220_004_0	4	2	Preventive - $0	11	14a;14d;14e1;14e2;14e3;14e4;14e5;	14b;	2			2			2				2	
H7220	011	0	1	02	01	H7220_011_0	3	1	40% Coinsurance	01	5;6;8a1;8a2;8b1;8b2;11c;15;16b;17b;		1	40	40	2			2				2	
H7220	011	0	1	02	01	H7220_011_0	3	2	$0 Copay	11	9d;14a;14d;14e1;14e2;14e3;14e4;14e5;	14b;	2			2			2				2	
H7220	011	0	1	02	01	H7220_011_0	3	3	$55 copay	01	7b;7c;7d;7e;7f;7g;7h;7i;7k;9c;17a;18a;		2			1	55.00	55.00	2				2	
H7220	011	0	1	02	01	H7220_011_0	3	4	50% coinsurance	01	11a;11b;12;		1	50	50	2			2				2	
H7220	011	0	1	02	01	H7220_011_0	3	5	$50 copay	01	8b3;		2			1	50.00	50.00	2				2	
H7220	011	0	1	02	01	H7220_011_0	3	6	$375 copay	01	9a1;9a2;9b;		2			1	375.00	375.00	2				2	
H7220	011	0	1	02	01	H7220_011_0	3	7	$20 copay	01	3-1;3-2;3-3;3-4;		2			1	20.00	20.00	2				2	
H7220	011	0	1	02	01	H7220_011_0	3	8	$15 Copay	01	7a;		2			1	15.00	15.00	2				2	
H7220	806	0	1	02	01	H7220_806_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H7220	806	0	1	02	01	H7220_806_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H7220	807	0	1	02	01	H7220_807_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H7220	807	0	1	02	01	H7220_807_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H7464	001	0	1	02	01	H7464_001_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H7464	005	0	1	02	01	H7464_005_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H7464	006	0	1	02	01	H7464_006_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H7464	007	0	1	02	01	H7464_007_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H7464	008	1	1	02	01	H7464_008_1	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H7464	008	2	1	02	01	H7464_008_2	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H7464	011	0	1	02	01	H7464_011_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H7464	011	0	1	02	01	H7464_011_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H7464	012	0	1	02	01	H7464_012_0	4	1	Group 1	10		16a;16b;	2			1	0.00	0.00	2				2	
H7464	013	0	1	02	01	H7464_013_0	5	1	Group 1	10		16a;	2			1	0.00	0.00	2				2	
H7464	013	0	1	02	01	H7464_013_0	5	2	Group 2	10		16b;	1	0	50	2			2				2	
H7646	001	0	1	02	01	H7646_001_0	5	1	Services with 20% Coins	11	3-1;3-2;3-3;3-4;5;6;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	18a;18a2;	1	20	20	2			2				2	
H7646	001	0	1	02	01	H7646_001_0	5	2	Ambulance Services	01	10a1;10a2;		2			1	200.00	200.00	2				2	
H7646	001	0	1	02	01	H7646_001_0	5	3	Hearing Aids	10		18b;	2			2			1	1000.00	2		2	
H7646	001	0	1	02	01	H7646_001_0	5	4	Eyewear/Exams	10		17a;17b;	2			2			2				2	
H7646	001	0	1	02	01	H7646_001_0	5	5	Medicare Part B Drugs	01	15;		1	0	20	1	35.00	35.00	2				2	
H7646	002	0	1	02	01	H7646_002_0	5	1	Services with 20% Coins	11	3-1;3-2;3-3;3-4;5;6;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	18a;18a2;	1	20	20	2			2				2	
H7646	002	0	1	02	01	H7646_002_0	5	2	Ambulance Services	01	10a1;10a2;		2			1	200.00	200.00	2				2	
H7646	002	0	1	02	01	H7646_002_0	5	3	Hearing Aids	10		18b;	2			2			1	1000.00	2		2	
H7646	002	0	1	02	01	H7646_002_0	5	4	Eyewear/Exams	10		17a;17b;	2			2			2				2	
H7646	002	0	1	02	01	H7646_002_0	5	5	Medicare Part B Drugs	01	15;		1	0	20	1	35.00	35.00	2				2	
H7646	004	0	1	02	01	H7646_004_0	5	1	Services with 20% Coins	11	3-1;3-2;3-3;3-4;5;6;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	18a;18a2;	1	20	20	2			2				2	
H7646	004	0	1	02	01	H7646_004_0	5	2	Ambulance Services	01	10a1;10a2;		2			1	200.00	200.00	2				2	
H7646	004	0	1	02	01	H7646_004_0	5	3	Hearing Aids	10		18b;	2			2			1	1500.00	2		2	
H7646	004	0	1	02	01	H7646_004_0	5	4	Eyewear/Exams	10		17a;17b;	2			2			2				2	
H7646	004	0	1	02	01	H7646_004_0	5	5	Medicare Part B Drugs	01	15;		1	0	20	1	35.00	35.00	2				2	
H7646	005	0	1	02	01	H7646_005_0	5	1	Services with 20% Coins	11	3-1;3-2;3-3;3-4;5;6;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	18a;18a2;	1	20	20	2			2				2	
H7646	005	0	1	02	01	H7646_005_0	5	2	Ambulance Services	01	10a1;10a2;		2			1	200.00	200.00	2				2	
H7646	005	0	1	02	01	H7646_005_0	5	3	Hearing Aids	10		18b;	2			2			1	1500.00	2		2	
H7646	005	0	1	02	01	H7646_005_0	5	4	Eyewear/Exams	10		17a;17b;	2			2			2				2	
H7646	005	0	1	02	01	H7646_005_0	5	5	Medicare Part B Drugs	01	15;		1	0	20	1	35.00	35.00	2				2	
H7646	007	0	1	02	01	H7646_007_0	5	1	Services with 20% Coins	11	3-1;3-2;3-3;3-4;5;6;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	18a;18a2;	1	20	20	2			2				2	
H7646	007	0	1	02	01	H7646_007_0	5	2	Ambulance Services	01	10a1;10a2;		2			1	200.00	200.00	2				2	
H7646	007	0	1	02	01	H7646_007_0	5	3	Hearing Aids	10		18b;	2			2			1	1000.00	2		2	
H7646	007	0	1	02	01	H7646_007_0	5	4	Eyewear/Exams	10		17a;17b;	2			2			2				2	
H7646	007	0	1	02	01	H7646_007_0	5	5	Medicare Part B Drugs	01	15;		1	0	20	1	35.00	35.00	2				2	
H7646	008	0	1	02	01	H7646_008_0	5	1	Services with 20% Coins	11	3-1;3-2;3-3;3-4;5;6;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	18a;18a2;	1	20	20	2			2				2	
H7646	008	0	1	02	01	H7646_008_0	5	2	Ambulance Services	01	10a1;10a2;		2			1	200.00	200.00	2				2	
H7646	008	0	1	02	01	H7646_008_0	5	3	Hearing Aids	10		18b;	2			2			1	1500.00	2		2	
H7646	008	0	1	02	01	H7646_008_0	5	4	Eyewear/Exams	10		17a;17b;	2			2			2				2	
H7646	008	0	1	02	01	H7646_008_0	5	5	Medicare Part B Drugs	01	15;		1	0	20	1	35.00	35.00	2				2	
H7646	801	0	1	02	01	H7646_801_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H7646	801	0	1	02	01	H7646_801_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H7646	802	0	1	02	01	H7646_802_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H7646	802	0	1	02	01	H7646_802_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H7646	803	0	1	02	01	H7646_803_0	2	1	Point of Service Group 1	01	6;14a;		1	0	0	2			2				2	
H7646	803	0	1	02	01	H7646_803_0	2	2	Point of Service Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H7646	804	0	1	02	01	H7646_804_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H7646	804	0	1	02	01	H7646_804_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H7646	805	0	1	02	01	H7646_805_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H7646	805	0	1	02	01	H7646_805_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H7746	003	0	1	02	01	H7746_003_0	6	1	POS 1	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;	9d_2;14b;	1	30	30	2			2				2	
H7746	003	0	1	02	01	H7746_003_0	6	2	POS 2	01	12;		1	20	30	2			2				2	
H7746	003	0	1	02	01	H7746_003_0	6	3	POS 3	01	15;		1	0	30	1	0.00	35.00	2				2	
H8019	002	0	1	02	01	H8019_002_0	6	1	40 coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;18a;	7b;7f_2;14b;16b;	1	40	40	2			2				2	
H8019	002	0	1	02	01	H8019_002_0	6	2	300 copay	11	10a1;10a2;	13d;	2			1	300.00	300.00	2				2	
H8019	002	0	1	02	01	H8019_002_0	6	3	50% Coinsurance				1	50	50	2			1	1000.00	3		2	
H8019	002	0	1	02	01	H8019_002_0	6	4	$0	10		16a;	2			2			1	1000.00	3		2	
H8019	003	0	1	02	01	H8019_003_0	4	1	75 copay				2			1	75.00	75.00	2				2	
H8019	003	0	1	02	01	H8019_003_0	4	2	40 coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;18a;	7b;7f_2;14b;	1	40	40	2			2				2	
H8019	003	0	1	02	01	H8019_003_0	4	3	300 Copay	11	10a1;10a2;	13d;	2			1	300.00	300.00	2				2	
H8019	003	0	1	02	01	H8019_003_0	4	4	50% coinsurance	10		16b;	1	50	50	2			1	1000.00	3		2	
H8019	003	0	1	02	01	H8019_003_0	4	5	$0	10		16a;	2			2			1	1000.00	3		2	
H8019	007	0	1	02	01	H8019_007_0	6	1	40 coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;18a;	7b;7f_2;14b;	1	40	40	2			2				2	
H8019	007	0	1	02	01	H8019_007_0	6	2	300 copay	11	10a1;10a2;	13d;	2			1	300.00	300.00	2				2	
H8019	007	0	1	02	01	H8019_007_0	6	3	$0				2			2			1	1000.00	3		2	
H8019	008	0	1	02	01	H8019_008_0	7	1	40 coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;18a;	7b;7f_2;14b;	1	40	40	2			2				2	
H8019	008	0	1	02	01	H8019_008_0	7	2	300 copay				2			1	300.00	300.00	2				2	
H8019	008	0	1	02	01	H8019_008_0	7	3	$0 Copay for Ambulance	11	10a1;10a2;	13d;	2			2			2				2	
H8019	804	0	1	02	01	H8019_804_0	1	1	Point of Service Group 1	01	6;14a;		1	0	0	2			2				2	
H8019	804	0	1	02	01	H8019_804_0	1	2	20% Coinsurance	01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9b;9c;9d;11a;11b;11c;12;14d;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H8019	805	0	1	02	01	H8019_805_0	1	1	Point of Service Group 1	01	6;14a;		1	0	0	2			2				2	
H8019	805	0	1	02	01	H8019_805_0	1	2	20% Coinsurance	01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9b;9c;9d;11a;11b;11c;12;14d;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H8019	806	0	1	02	01	H8019_806_0	2	1	Point of Service Group 1	01	6;14a;		1	0	0	2			2				2	
H8019	806	0	1	02	01	H8019_806_0	2	2	20% Coinsurance	01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9b;9c;9d;11a;11b;11c;12;14d;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H8095	807	0	1	02	01	H8095_807_0	6	1		01	6;14a;		2			2								
H8095	808	0	1	02	01	H8095_808_0	6	1		01	6;14a;		2			2								
H8142	001	0	1	02	01	H8142_001_0	17	1	Dental	10		16a;16b;	1	0	50	2			1	3500.00	3		2	
H8142	002	0	1	02	01	H8142_002_0	17	1	Dental	10		16a;16b;	1	0	50	2			1	3500.00	3		2	
H8142	003	0	1	02	01	H8142_003_0	10	1	POS	10		16a;16b;	1	0	50	2			1	3500.00	3		2	
H8142	004	0	1	02	01	H8142_004_0	16	1	Dental	10		16a;16b;	1	0	50	2			1	3500.00	3		2	
H8142	005	0	1	02	01	H8142_005_0	17	1	Dental	10		16a;16b;	1	0	50	2			1	3500.00	3		2	
H8142	006	0	1	02	01	H8142_006_0	11	1	Dental	10		16a;16b;	1	0	50	2			1	3500.00	3		2	
H8142	007	0	1	02	01	H8142_007_0	20	1	Dental	10		16a;16b;	1	0	50	2			1	3500.00	3		2	
H8142	008	0	1	02	01	H8142_008_0	16	1	Dental	10		16a;16b;	1	0	50	2			1	3500.00	3		2	
H8142	009	0	1	02	01	H8142_009_0	17	1	Dental	10		16a;16b;	1	0	50	2			1	3500.00	3		2	
H8142	010	0	1	02	01	H8142_010_0	21	1	Dental	10		16a;16b;	1	0	50	2			1	3500.00	3		2	
H8142	801	0	1	02	01	H8142_801_0	1	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H8142	801	0	1	02	01	H8142_801_0	1	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H8142	802	0	1	02	01	H8142_802_0	1	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H8142	802	0	1	02	01	H8142_802_0	1	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H8142	803	0	1	02	01	H8142_803_0	1	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H8142	803	0	1	02	01	H8142_803_0	1	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H8142	804	0	1	02	01	H8142_804_0	1	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H8142	804	0	1	02	01	H8142_804_0	1	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H8578	801	0	1	02	01	H8578_801_0	3	1	Point of Service Group 1	01	6;14a;		1	0	0	2			2				2	
H8578	801	0	1	02	01	H8578_801_0	3	2	Point of Service Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H8578	802	0	1	02	01	H8578_802_0	3	1	Point of Service Group 1	01	6;14a;		1	0	0	2			2				2	
H8578	802	0	1	02	01	H8578_802_0	3	2	Point of Service Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H8578	803	0	1	02	01	H8578_803_0	3	1	Point of Service Group 1	01	6;14a;		1	0	0	2			2				2	
H8578	803	0	1	02	01	H8578_803_0	3	2	Point of Service Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H8649	003	0	1	02	01	H8649_003_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H8649	008	0	1	02	01	H8649_008_0	7	1	20% coinsurance	10		16a;16b;	1	20	20	2			2				2	
H8764	002	0	1	02	01	H8764_002_0	7	1	Point of Service Group 1	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a2;11a;11b;11c;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	30	30	2			2				2	
H8764	002	0	1	02	01	H8764_002_0	7	2	Point of Service Group 2	01	10a1;		2			1	300.00	300.00	2				2	
H8764	002	0	1	02	01	H8764_002_0	7	3	Point of Service Group 3	01	14a;		2			2			2				2	
H8764	002	0	1	02	01	H8764_002_0	7	4	Point of Service Group 4	01	12;		1	20	20	2			2				2	
H8764	801	0	1	02	01	H8764_801_0	3	1	group1	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H8797	003	0	1	02	01	H8797_003_0	10	1	$0 Cost Share Group	01	7a;		2			2			2				2	
H8797	003	0	1	02	01	H8797_003_0	10	2	$20 Copay Group	01	7d;		2			1	20.00	20.00	2				2	
H8797	004	0	1	02	01	H8797_004_0	10	1	$0 Cost Share Group	01	7a;		2			2			2				2	
H8797	004	0	1	02	01	H8797_004_0	10	2	$20 Copay Group	01	7d;		2			1	20.00	20.00	2				2	
H8908	001	0	1	02	01	H8908_001_0	7	1	Point of Service Group 1	10		16a;16b;	2			1	0.00	0.00	1	1500.00	3		2	
H8908	004	0	1	02	01	H8908_004_0	7	1	POS Package Group 2	10		16a;16b;	2			1	0.00	0.00	1	2500.00	3		2	
H8908	004	0	1	02	01	H8908_004_0	7	2	POS Package Group 1	10		9d_2;	2			2			2				2	
H9003	001	0	1	02	01	H9003_001_0	10	1	Part B Drugs	01	15;		1	20	20	2			2				2	
H9003	001	0	1	02	01	H9003_001_0	10	2	Office Visits	11	3-1;3-2;7a;7b;7c;7d;7e;7f;7i;9c;14a;14e1;14e3;14e4;17a;18a;	14b;	2			1	0.00	55.00	2				2	
H9003	001	0	1	02	01	H9003_001_0	10	3	Outpatient Tests and Services	11	8a1;8a2;8b1;8b3;9d;14e5;	9d_2;	2			1	0.00	25.00	2				2	
H9003	006	0	1	02	01	H9003_006_0	10	1	Part B Drugs	01	15;		1	20	20	2			2				2	
H9003	006	0	1	02	01	H9003_006_0	10	2	Office Visits	11	3-1;3-2;7a;7b;7c;7d;7e;7f;7i;9c;14a;14e1;14e3;14e4;17a;18a;	14b;	2			1	0.00	55.00	2				2	
H9003	006	0	1	02	01	H9003_006_0	10	3	Outpatient Tests and Services	11	8a1;8a2;8b1;8b3;9d;14e5;	9d_2;	2			1	0.00	25.00	2				2	
H9003	008	0	1	02	01	H9003_008_0	11	1	Part B Drugs	01	15;		1	20	20	2			2				2	
H9003	008	0	1	02	01	H9003_008_0	11	2	Office Visits	11	3-1;3-2;7a;7b;7c;7d;7e;7f;7i;9c;14a;14e1;14e3;14e4;17a;18a;	14b;	2			1	0.00	55.00	2				2	
H9003	008	0	1	02	01	H9003_008_0	11	3	Outpatient Tests and Services	11	8a1;8a2;8b1;8b3;9d;14e5;	9d_2;	2			1	0.00	25.00	2				2	
H9003	009	0	1	02	01	H9003_009_0	10	1	Part B Drugs	01	15;		1	20	20	2			2				2	
H9003	009	0	1	02	01	H9003_009_0	10	2	Office Visits	11	3-1;3-2;7a;7b;7c;7d;7e;7f;7i;9c;14a;14e1;14e3;14e4;17a;18a;	14b;	2			1	0.00	55.00	2				2	
H9003	009	0	1	02	01	H9003_009_0	10	3	Outpatient Tests and Services	11	8a1;8a2;8b1;8b3;9d;14e5;	9d_2;	2			1	0.00	25.00	2				2	
H9047	035	0	1	02	01	H9047_035_0	6	1	PCP Visit	01	7a;		2			1	25.00	25.00	2				2	
H9047	035	0	1	02	01	H9047_035_0	6	2	Specialist Visit	01	7d;		2			1	50.00	50.00	2				2	
H9047	035	0	1	02	01	H9047_035_0	6	3	Ambulance	01	10a1;10a2;		2			1	50.00	250.00	2				2	
H9047	035	0	1	02	01	H9047_035_0	6	4	All Other Services	11	3-1;3-2;3-3;3-4;5;6;7b;7c;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	9d_2;14b;14c12;	1	30	30	2			2				2	
H9047	035	0	1	02	01	H9047_035_0	6	5	Routine Eye Exam	10		17a;	2			2			2				2	
H9047	035	0	1	02	01	H9047_035_0	6	6	Routine Eyewear	10		17b;	2			2			1	250.00	3		2	
H9047	035	0	1	02	01	H9047_035_0	6	7	Dialysis & Preventive Dental	11	12;	16a;	1	20	20	2			2				2	
H9047	059	0	1	02	01	H9047_059_0	10	1	PCP Visit	01	7a;		2			1	25.00	25.00	2				2	
H9047	059	0	1	02	01	H9047_059_0	10	2	Specialist Visit	01	7d;		2			1	50.00	50.00	2				2	
H9047	059	0	1	02	01	H9047_059_0	10	3	Ambulance	01	10a1;10a2;		2			1	50.00	250.00	2				2	
H9047	059	0	1	02	01	H9047_059_0	10	4	All Other Services	11	3-1;3-2;3-3;3-4;5;6;7b;7c;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	9d_2;14b;14c12;	1	30	30	2			2				2	
H9047	059	0	1	02	01	H9047_059_0	10	5	Routine Eye Exam	10		17a;	2			2			2				2	
H9047	059	0	1	02	01	H9047_059_0	10	6	Routine Eyewear	10		17b;	2			2			1	250.00	3		2	
H9047	059	0	1	02	01	H9047_059_0	10	7	Dialysis & Preventive Dental	11	12;	16a;	1	20	20	2			2				2	
H9047	062	0	1	02	01	H9047_062_0	11	1	PCP Visit	01	7a;		2			1	25.00	25.00	2				2	
H9047	062	0	1	02	01	H9047_062_0	11	2	Specialist Visit	01	7d;		2			1	50.00	50.00	2				2	
H9047	062	0	1	02	01	H9047_062_0	11	3	Ambulance	01	10a1;10a2;		2			1	50.00	250.00	2				2	
H9047	062	0	1	02	01	H9047_062_0	11	4	All Other Services	11	3-1;3-2;3-3;3-4;5;6;7b;7c;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	9d_2;14b;14c12;	1	30	30	2			2				2	
H9047	062	0	1	02	01	H9047_062_0	11	5	Routine Eye Exam	10		17a;	2			2			2				2	
H9047	062	0	1	02	01	H9047_062_0	11	6	Routine Eyewear	10		17b;	2			2			1	250.00	3		2	
H9047	062	0	1	02	01	H9047_062_0	11	7	Dialysis & Preventive Dental	11	12;	16a;	1	20	20	2			2				2	
H9047	065	0	1	02	01	H9047_065_0	10	1	PCP Visit	01	7a;		2			1	25.00	25.00	2				2	
H9047	065	0	1	02	01	H9047_065_0	10	2	Specialist Visit	01	7d;		2			1	50.00	50.00	2				2	
H9047	065	0	1	02	01	H9047_065_0	10	3	Ambulance	01	10a1;10a2;		2			1	50.00	250.00	2				2	
H9047	065	0	1	02	01	H9047_065_0	10	4	All Other Services	11	3-1;3-2;3-3;3-4;5;6;7b;7c;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	9d_2;14b;14c12;16a;	1	20	20	2			2				2	
H9047	065	0	1	02	01	H9047_065_0	10	5	Routine Eye Exam	10		17a;	2			2			2				2	
H9047	065	0	1	02	01	H9047_065_0	10	6	Routine Eyewear	10		17b;	2			2			1	250.00	3		2	
H9047	805	0	1	02	01	H9047_805_0	2	1	Group 1	01	6;14a;		1	0	0	2			2				2	
H9047	805	0	1	02	01	H9047_805_0	2	2	Group 2	01	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H9047	809	0	1	02	01	H9047_809_0	2	1		01	6;14a;		2			2								
H9065	002	0	1	02	01	H9065_002_0	9	1	30% Coinsurance	11	3-1;3-2;3-3;3-4;5;6;7b;7c;7e;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;	9d_2;	1	30	30	2			2				2	
H9065	002	0	1	02	01	H9065_002_0	9	2	20% Coinsurance	01	12;14a;		1	20	20	2			2				2	
H9065	002	0	1	02	01	H9065_002_0	9	3	$300 Ambulance	01	10a1;10a2;		2			1	300.00	300.00	2				2	
H9065	002	0	1	02	01	H9065_002_0	9	4	$50 Copay	01	7a;7d;7f;7g;18a;		2			1	50.00	50.00	2				2	
H9065	002	0	1	02	01	H9065_002_0	9	5	$0	10		16a;16b;	2			1	0.00	0.00	2				2	
H9065	002	0	1	02	01	H9065_002_0	9	6	Part B Rx Drugs	01	15;		1	0	30	1	35.00	35.00	2				2	
H9065	003	0	1	02	01	H9065_003_0	9	1	30% Coinsurance	11	3-1;3-2;3-3;3-4;5;6;7b;7e;7h;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;	9d_2;	1	30	30	2			2				2	
H9065	003	0	1	02	01	H9065_003_0	9	2	20% Coinsurance	01	10a2;12;14a;		1	20	20	2			2				2	
H9065	003	0	1	02	01	H9065_003_0	9	3	$300 Ground Ambulance	01	10a1;		2			1	300.00	300.00	2				2	
H9065	003	0	1	02	01	H9065_003_0	9	4	$50 Copay	01	7a;7c;7d;7f;7g;7i;18a;		2			1	50.00	50.00	2				2	
H9065	003	0	1	02	01	H9065_003_0	9	5	$0	10		16a;16b;	2			1	0.00	0.00	2				2	
H9065	003	0	1	02	01	H9065_003_0	9	6	Part B Rx Drugs	01	15;		1	0	30	1	35.00	35.00	2				2	
H9065	004	0	1	02	01	H9065_004_0	9	1	40% Coinsurance	11	3-1;3-2;3-3;3-4;5;6;7b;7e;7h;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;	9d_2;	1	40	40	2			2				2	
H9065	004	0	1	02	01	H9065_004_0	9	2	20% Coinsurance	01	10a2;12;		1	20	20	2			2				2	
H9065	004	0	1	02	01	H9065_004_0	9	3	$300 Ground Ambulance	01	10a1;		2			1	300.00	300.00	2				2	
H9065	004	0	1	02	01	H9065_004_0	9	4	$50 Copay	01	7a;7c;7d;7f;7g;7i;18a;		2			1	50.00	50.00	2				2	
H9065	004	0	1	02	01	H9065_004_0	9	5	$0	10		16a;16b;	2			1	0.00	0.00	2				2	
H9065	004	0	1	02	01	H9065_004_0	9	6	Part B Rx Drugs	01	15;		1	0	40	1	35.00	35.00	2				2	
H9096	001	0	1	02	01	H9096_001_0	6	1	20 coinsurance	01	10a2;		1	20	20	2			2				2	
H9096	001	0	1	02	01	H9096_001_0	6	2	40% coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;18a;	7b;7f_2;14b;	1	40	40	2			2				2	
H9096	001	0	1	02	01	H9096_001_0	6	3	$290 Copay	11	10a1;	13d;	2			1	290.00	290.00	2				2	
H9096	002	0	1	02	01	H9096_002_0	6	1	30 copay	11	14a;14d;14e1;14e2;14e3;14e4;14e5;	14b;	2			1	30.00	30.00	2				2	
H9096	002	0	1	02	01	H9096_002_0	6	2	100 copay	01	5;		2			1	100.00	100.00	2				2	
H9096	002	0	1	02	01	H9096_002_0	6	3	20 coinsurance	01	6;8a1;8a2;9d;10a2;12;15;		1	20	20	2			2				2	
H9096	002	0	1	02	01	H9096_002_0	6	4	60 copay	11	3-1;3-2;3-3;3-4;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;9c;16b;17a;18a;	7b;7f_2;	2			1	60.00	60.00	2				2	
H9096	002	0	1	02	01	H9096_002_0	6	5	40 coinsurance	01	8b1;8b2;8b3;9a1;9a2;9b;11a;11b;11c;		1	40	40	2			2				2	
H9096	002	0	1	02	01	H9096_002_0	6	6	$275 Copay	11	10a1;	13d;	2			1	275.00	275.00	2				2	
H9096	010	0	1	02	01	H9096_010_0	4	1	20 coinsurance	01	10a2;		1	20	20	2			2				2	
H9096	010	0	1	02	01	H9096_010_0	4	2	40 coinsurance	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11a;11b;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;18a;	7b;7f_2;14b;	1	40	40	2			2				2	
H9096	010	0	1	02	01	H9096_010_0	4	3	$290 Copay	11	10a1;	13d;	2			1	290.00	290.00	2				2	
H9096	804	0	1	02	01	H9096_804_0	2	1	0% Coinsurance	01	6;14a;		2			2			2				2	
H9096	804	0	1	02	01	H9096_804_0	2	2	20% Coinsurance	01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9b;9c;9d;11a;11b;11c;12;14d;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H9096	805	0	1	02	01	H9096_805_0	2	1	No Costsharing	01	6;14a;		2			2			2				2	
H9096	805	0	1	02	01	H9096_805_0	2	2	20% Coinsurance	01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9b;9c;9d;11a;11b;11c;12;14d;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H9096	806	0	1	02	01	H9096_806_0	2	1	0% cost sharing	01	6;14a;		2			2			2				2	
H9096	806	0	1	02	01	H9096_806_0	2	2	20% Coinsurance	01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9b;9c;9d;11a;11b;11c;12;14d;15;16b;17a;17b;18a;		1	20	20	2			2				2	
H9147	001	0	1	02	01	H9147_001_0	7	1	POS Dental	10		16a;16b;	2			1	0.00	0.00	2				2	
H9207	002	0	1	02	01	H9207_002_0	10	1	Place of Service Co-insurance Group	11	7d;7e;7f;7h;7k;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;18a;	14b;	1	20	20	2			2				2	
H9207	012	0	1	02	01	H9207_012_0	11	1	Place of Service Co-insurance Group	11	7d;7e;7f;7h;7k;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;18a;	14b;	1	20	20	2			2				2	
H9207	013	0	1	02	01	H9207_013_0	10	1	Place of Service Co-insurance Group	11	7d;7e;7f;7h;7k;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;18a;	14b;	1	20	20	2			2				2	
H9207	014	0	1	02	01	H9207_014_0	11	1	Place of Service Co-insurance Group	11	7d;7e;7f;7h;7k;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;18a;	14b;	1	20	20	2			2				2	
H9207	015	0	1	02	01	H9207_015_0	12	1	Place of Service Co-insurance Group	11	7d;7e;7f;7h;7k;12;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;18a;	14b;	1	20	20	2			2				2	
H9489	802	0	1	02	01	H9489_802_0	6	1		01	6;14a;		2			2								
H9489	804	0	1	02	01	H9489_804_0	6	1		01	6;14a;		2			2								
H9489	806	0	1	02	01	H9489_806_0	6	1		01	6;14a;		2			2								
H9489	808	0	1	02	01	H9489_808_0	6	1		01	6;14a;		2			2								
H9730	005	0	1	02	01	H9730_005_0	6	1	35%	01	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;14a;14d;14e1;14e2;14e3;14e4;14e5;16b;17a;17b;18a;		1	35	35	2			2				2	
H9730	005	0	1	02	01	H9730_005_0	6	2	Insulin/Part B Drugs and Dialysis	01	12;15;		1	0	20	1	35.00	35.00	2				2	
H9763	004	1	1	02	01	H9763_004_1	8	1	20% Cost Sharing	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	9d_2;	1	20	20	2			2				2	
H9763	004	2	1	02	01	H9763_004_2	9	1	20% Cost Sharing	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	9d_2;	1	20	20	2			2				2	
H9763	006	0	1	02	01	H9763_006_0	7	1	30% Cost Sharing	11	3-1;3-2;3-3;3-4;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;10a1;10a2;11a;11b;11c;12;14d;14e1;14e2;14e3;14e4;14e5;15;16b;17a;17b;18a;	9d_2;	1	30	30	2			2				2	
H9861	001	0	1	02	01	H9861_001_0	11	1	50% Coinsurance	11	3-1;3-2;3-3;3-4;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c;9d;11c;12;14a;14d;14e1;14e2;14e3;14e4;14e5;17a;18a;	9d_2;	1	50	50	2			2				2	
H9861	001	0	1	02	01	H9861_001_0	11	2	$0 Copay	01	6;		2			2			2				2	
H9861	001	0	1	02	01	H9861_001_0	11	3	Ambulance Copay	01	10a1;10a2;		2			1	240.00	300.00	2				2	
H9861	001	0	1	02	01	H9861_001_0	11	4	30% Coinsurance	01	11a;11b;		1	30	30	2			2				2	
H9861	001	0	1	02	01	H9861_001_0	11	5	Vendored OON Benefits.	10		17a;18a;	2			2			2				2	
H9861	001	0	1	02	01	H9861_001_0	11	6	Part B Drugs	01	15;		1	20	50	2			2				2	
H9943	001	0	1	02	01	H9943_001_0	13	1																
H9943	002	0	1	02	01	H9943_002_0	13	1																
H9943	005	0	1	02	01	H9943_005_0	13	1																
