pbp_a_hnumber	pbp_a_plan_identifier	segment_id	pbp_a_ben_cov	pbp_a_plan_type	orgtype	bid_id	version	pbp_c_oon_outpt_group_num_id	pbp_c_oon_outpt_grp_lbl	pbp_c_oon_outpt_bendesc_ben	pbp_c_oon_out_mc_bendesc_cats	pbp_c_oon_out_nmc_bendesc_cats	pbp_c_oon_outpt_maxplan_yn	pbp_c_oon_outpt_maxplan_amt	pbp_c_oon_outpt_copay_yn	pbp_c_oon_outpt_copay_min_amt	pbp_c_oon_outpt_copay_max_amt	pbp_c_oon_outpt_ded_yn	pbp_c_oon_outpt_ded_amt	pbp_c_oon_outpt_cost_share	pbp_c_oon_outpt_coins_yn	pbp_c_oon_outpt_cs_coins_yn	pbp_c_oon_outpt_cs_coins_min	pbp_c_oon_outpt_coins_min_pct	pbp_c_oon_outpt_coins_max_pct	pbp_c_oon_outpt_cs_coins_max	pbp_c_oon_outpt_cs_copay_yn	pbp_c_oon_outpt_cs_copay_min	pbp_c_oon_outpt_cs_copay_max
H0084	001	0	1	04	01	H0084_001_0	6	1	$40 copayment	01	011110001101101000000000000000000011		2		1	40.00	40.00	2		2	2								
H0084	001	0	1	04	01	H0084_001_0	6	10	$175 copayment	01	000000000000000000000001000000000000		2		1	175.00	175.00	2		2	2								
H0084	001	0	1	04	01	H0084_001_0	6	11	35% Co-insurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	001	0	1	04	01	H0084_001_0	6	12	$0 to $40 Copayment	01	000000000000000000000000000000000100		2		1	0.00	40.00	2		2	2								
H0084	001	0	1	04	01	H0084_001_0	6	13	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	001	0	1	04	01	H0084_001_0	6	2	40% coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	001	0	1	04	01	H0084_001_0	6	9	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	001	0	1	04	01	H0084_001_0	6	4	$20 to $40 copayment	01	000000000010010000000100000000000000		2		1	20.00	40.00	2		2	2								
H0084	001	0	1	04	01	H0084_001_0	6	5	$10 copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	001	0	1	04	01	H0084_001_0	6	6	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	001	0	1	04	01	H0084_001_0	6	7	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	001	0	1	04	01	H0084_001_0	6	8	$250 Copayment	01	000000000000000000011000000000000000		2		1	250.00	250.00	2		2	2								
H0084	001	0	1	04	01	H0084_001_0	6	3	$20 copayment	01	000000110000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	003	0	1	04	01	H0084_003_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	003	0	1	04	01	H0084_003_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000001010100000010011100	2		1	0.00	0.00	2		2	2								
H0084	003	0	1	04	01	H0084_003_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	003	0	1	04	01	H0084_003_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	003	0	1	04	01	H0084_003_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	004	0	1	04	01	H0084_004_0	4	1	$50 Copayment	01	011100001101101000000000000000000111		2		1	50.00	50.00	2		2	2								
H0084	004	0	1	04	01	H0084_004_0	4	10	$150 Copayment	01	000000000000000000011000000000000000		2		1	150.00	150.00	2		2	2								
H0084	004	0	1	04	01	H0084_004_0	4	9	$15 Copayment	01	000000000000000000100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	004	0	1	04	01	H0084_004_0	4	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	004	0	1	04	01	H0084_004_0	4	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	004	0	1	04	01	H0084_004_0	4	6	$25 to $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
H0084	004	0	1	04	01	H0084_004_0	4	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	004	0	1	04	01	H0084_004_0	4	4	$25 Copayment	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H0084	004	0	1	04	01	H0084_004_0	4	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	004	0	1	04	01	H0084_004_0	4	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H0084	004	0	1	04	01	H0084_004_0	4	15	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	004	0	1	04	01	H0084_004_0	4	11	$0 Copayment	11	000000000000000000000010001011101100	000001110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	004	0	1	04	01	H0084_004_0	4	12	$160 Copayment	01	000000000000000000000001000000000000		2		1	160.00	160.00	2		2	2								
H0084	004	0	1	04	01	H0084_004_0	4	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	004	0	1	04	01	H0084_004_0	4	14	$14 Copayment	01	000000000000000100000000000000000000		2		1	14.00	14.00	2		2	2								
H0084	005	0	1	04	01	H0084_005_0	3	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	005	0	1	04	01	H0084_005_0	3	4	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	005	0	1	04	01	H0084_005_0	3	3	$0 Copayment	11	000001000000000000000000000011100000	000000010000000010011100	2		1	0.00	0.00	2		2	2								
H0084	005	0	1	04	01	H0084_005_0	3	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	005	0	1	04	01	H0084_005_0	3	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	006	0	1	04	01	H0084_006_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000001010100000010011100	2		1	0.00	0.00	2		2	2								
H0084	006	0	1	04	01	H0084_006_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	006	0	1	04	01	H0084_006_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	006	0	1	04	01	H0084_006_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	006	0	1	04	01	H0084_006_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	007	0	1	04	01	H0084_007_0	4	1	$50 Copayment	01	011100001101101000000000000000000111		2		1	50.00	50.00	2		2	2								
H0084	007	0	1	04	01	H0084_007_0	4	10	$175 Copayment	01	000000000000000000011001000000000000		2		1	175.00	175.00	2		2	2								
H0084	007	0	1	04	01	H0084_007_0	4	9	$15 Copayment	01	000000000000000000100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	007	0	1	04	01	H0084_007_0	4	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	007	0	1	04	01	H0084_007_0	4	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	007	0	1	04	01	H0084_007_0	4	6	$25 to $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
H0084	007	0	1	04	01	H0084_007_0	4	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	007	0	1	04	01	H0084_007_0	4	4	$25 Copayment	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H0084	007	0	1	04	01	H0084_007_0	4	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	007	0	1	04	01	H0084_007_0	4	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H0084	007	0	1	04	01	H0084_007_0	4	14	$13 Copayment	01	000000000000000100000000000000000000		2		1	13.00	13.00	2		2	2								
H0084	007	0	1	04	01	H0084_007_0	4	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	007	0	1	04	01	H0084_007_0	4	12	$340 to $390 Copaymnet	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	007	0	1	04	01	H0084_007_0	4	11	$0 Copayment	11	000000000000000000000010001011101100	000001110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	009	0	1	04	01	H0084_009_0	4	1	$50 Copayment	01	011100001101101000000000000000000011		2		1	50.00	50.00	2		2	2								
H0084	009	0	1	04	01	H0084_009_0	4	9	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	009	0	1	04	01	H0084_009_0	4	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	009	0	1	04	01	H0084_009_0	4	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	009	0	1	04	01	H0084_009_0	4	6	$30 to $40 Copayment	01	000000000010010000000100000000000000		2		1	30.00	40.00	2		2	2								
H0084	009	0	1	04	01	H0084_009_0	4	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	009	0	1	04	01	H0084_009_0	4	4	$30 Copayment	01	000000100000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H0084	009	0	1	04	01	H0084_009_0	4	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	009	0	1	04	01	H0084_009_0	4	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H0084	009	0	1	04	01	H0084_009_0	4	15	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	009	0	1	04	01	H0084_009_0	4	14	$0 to $50 Copayment	01	000000000000000000000000000000000100		2		1	0.00	50.00	2		2	2								
H0084	009	0	1	04	01	H0084_009_0	4	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	009	0	1	04	01	H0084_009_0	4	12	$175 Copayment	01	000000000000000000000001000000000000		2		1	175.00	175.00	2		2	2								
H0084	009	0	1	04	01	H0084_009_0	4	11	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	009	0	1	04	01	H0084_009_0	4	10	$250 Copayment	01	000000000000000000011000000000000000		2		1	250.00	250.00	2		2	2								
H0084	010	0	1	04	01	H0084_010_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000001010100000010011100	2		1	0.00	0.00	2		2	2								
H0084	010	0	1	04	01	H0084_010_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	010	0	1	04	01	H0084_010_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	010	0	1	04	01	H0084_010_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	010	0	1	04	01	H0084_010_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	011	0	1	04	01	H0084_011_0	4	14	$13 Copayment	01	000000000000000100000000000000000000		2		1	13.00	13.00	2		2	2								
H0084	011	0	1	04	01	H0084_011_0	4	15	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	011	0	1	04	01	H0084_011_0	4	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H0084	011	0	1	04	01	H0084_011_0	4	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	011	0	1	04	01	H0084_011_0	4	4	$25 Copayment	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H0084	011	0	1	04	01	H0084_011_0	4	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	011	0	1	04	01	H0084_011_0	4	6	$25 to $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
H0084	011	0	1	04	01	H0084_011_0	4	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	011	0	1	04	01	H0084_011_0	4	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	011	0	1	04	01	H0084_011_0	4	9	$15 Copayment	01	000000000000000000100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	011	0	1	04	01	H0084_011_0	4	12	$180 Copayment	01	000000000000000000000001000000000000		2		1	180.00	180.00	2		2	2								
H0084	011	0	1	04	01	H0084_011_0	4	11	$0 Copayment	11	000000000000000000000010001011101100	000001110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	011	0	1	04	01	H0084_011_0	4	10	$175 Copayment	01	000000000000000000011000000000000000		2		1	175.00	175.00	2		2	2								
H0084	011	0	1	04	01	H0084_011_0	4	1	$50 Copayment	01	011100001101101000000000000000000111		2		1	50.00	50.00	2		2	2								
H0084	011	0	1	04	01	H0084_011_0	4	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	012	0	1	04	01	H0084_012_0	3	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	012	0	1	04	01	H0084_012_0	3	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	012	0	1	04	01	H0084_012_0	3	3	$0 Copayment	11	000001000000000000000000000011100000	000000010000000010011100	2		1	0.00	0.00	2		2	2								
H0084	012	0	1	04	01	H0084_012_0	3	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	012	0	1	04	01	H0084_012_0	3	4	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	013	0	1	04	01	H0084_013_0	4	1	$50 Copayment	01	011100001101101000000000000000000011		2		1	50.00	50.00	2		2	2								
H0084	013	0	1	04	01	H0084_013_0	4	10	$250 Copayment	01	000000000000000000011000000000000000		2		1	250.00	250.00	2		2	2								
H0084	013	0	1	04	01	H0084_013_0	4	9	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	013	0	1	04	01	H0084_013_0	4	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	013	0	1	04	01	H0084_013_0	4	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	013	0	1	04	01	H0084_013_0	4	6	$30 to $40 Copayment	01	000000000010010000000100000000000000		2		1	30.00	40.00	2		2	2								
H0084	013	0	1	04	01	H0084_013_0	4	11	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	013	0	1	04	01	H0084_013_0	4	12	$175 Copayment	01	000000000000000000000001000000000000		2		1	175.00	175.00	2		2	2								
H0084	013	0	1	04	01	H0084_013_0	4	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	013	0	1	04	01	H0084_013_0	4	14	$0 to $50 Copayment	01	000000000000000000000000000000000100		2		1	0.00	50.00	2		2	2								
H0084	013	0	1	04	01	H0084_013_0	4	15	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	013	0	1	04	01	H0084_013_0	4	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H0084	013	0	1	04	01	H0084_013_0	4	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	013	0	1	04	01	H0084_013_0	4	4	$30 Copayment	01	000000100000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H0084	013	0	1	04	01	H0084_013_0	4	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	014	0	1	04	01	H0084_014_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000001010100000010011100	2		1	0.00	0.00	2		2	2								
H0084	014	0	1	04	01	H0084_014_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	014	0	1	04	01	H0084_014_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	014	0	1	04	01	H0084_014_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	014	0	1	04	01	H0084_014_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	015	0	1	04	01	H0084_015_0	4	9	$15 Copayment	01	000000000000000000100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	015	0	1	04	01	H0084_015_0	4	1	$50 Copayment	01	011100001101101000000000000000000111		2		1	50.00	50.00	2		2	2								
H0084	015	0	1	04	01	H0084_015_0	4	10	$175 Copayment	01	000000000000000000011000000000000000		2		1	175.00	175.00	2		2	2								
H0084	015	0	1	04	01	H0084_015_0	4	11	$0 Copayment	11	000000000000000000000010001011101100	000001110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	015	0	1	04	01	H0084_015_0	4	12	$190 Copayment	01	000000000000000000000001000000000000		2		1	190.00	190.00	2		2	2								
H0084	015	0	1	04	01	H0084_015_0	4	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	015	0	1	04	01	H0084_015_0	4	14	$13 Copayment	01	000000000000000100000000000000000000		2		1	13.00	13.00	2		2	2								
H0084	015	0	1	04	01	H0084_015_0	4	15	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	015	0	1	04	01	H0084_015_0	4	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H0084	015	0	1	04	01	H0084_015_0	4	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	015	0	1	04	01	H0084_015_0	4	4	$25 Copayment	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H0084	015	0	1	04	01	H0084_015_0	4	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	015	0	1	04	01	H0084_015_0	4	6	$25 to $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
H0084	015	0	1	04	01	H0084_015_0	4	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	015	0	1	04	01	H0084_015_0	4	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	016	0	1	04	01	H0084_016_0	3	4	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	016	0	1	04	01	H0084_016_0	3	3	$0 Copayment	11	000001000000000000000000000011100000	000000010000000010011100	2		1	0.00	0.00	2		2	2								
H0084	016	0	1	04	01	H0084_016_0	3	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	016	0	1	04	01	H0084_016_0	3	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	016	0	1	04	01	H0084_016_0	3	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	017	0	1	04	01	H0084_017_0	4	14	$0 to $50 Copayment	01	000000000000000000000000000000000100		2		1	0.00	50.00	2		2	2								
H0084	017	0	1	04	01	H0084_017_0	4	15	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	017	0	1	04	01	H0084_017_0	4	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H0084	017	0	1	04	01	H0084_017_0	4	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	017	0	1	04	01	H0084_017_0	4	4	$30 Copayment	01	000000100000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H0084	017	0	1	04	01	H0084_017_0	4	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	017	0	1	04	01	H0084_017_0	4	6	$30 to $40 Copayment	01	000000000010010000000100000000000000		2		1	30.00	40.00	2		2	2								
H0084	017	0	1	04	01	H0084_017_0	4	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	017	0	1	04	01	H0084_017_0	4	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	017	0	1	04	01	H0084_017_0	4	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	017	0	1	04	01	H0084_017_0	4	12	$190 Copayment	01	000000000000000000000001000000000000		2		1	190.00	190.00	2		2	2								
H0084	017	0	1	04	01	H0084_017_0	4	11	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	017	0	1	04	01	H0084_017_0	4	10	$250 Copayment	01	000000000000000000011000000000000000		2		1	250.00	250.00	2		2	2								
H0084	017	0	1	04	01	H0084_017_0	4	1	$50 Copayment	01	011100001101101000000000000000000011		2		1	50.00	50.00	2		2	2								
H0084	017	0	1	04	01	H0084_017_0	4	9	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	018	0	1	04	01	H0084_018_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	018	0	1	04	01	H0084_018_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	018	0	1	04	01	H0084_018_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	018	0	1	04	01	H0084_018_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	018	0	1	04	01	H0084_018_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000001010100000010011100	2		1	0.00	0.00	2		2	2								
H0084	019	0	1	04	01	H0084_019_0	4	14	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	019	0	1	04	01	H0084_019_0	4	2	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	019	0	1	04	01	H0084_019_0	4	3	$25 Copayment	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H0084	019	0	1	04	01	H0084_019_0	4	4	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	019	0	1	04	01	H0084_019_0	4	5	$25 ot $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
H0084	019	0	1	04	01	H0084_019_0	4	6	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	019	0	1	04	01	H0084_019_0	4	7	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	019	0	1	04	01	H0084_019_0	4	8	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	019	0	1	04	01	H0084_019_0	4	9	$150 Copayment	01	000000000000000000011000000000000000		2		1	150.00	150.00	2		2	2								
H0084	019	0	1	04	01	H0084_019_0	4	12	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	019	0	1	04	01	H0084_019_0	4	11	$160 Copayment	01	000000000000000000000001000000000000		2		1	160.00	160.00	2		2	2								
H0084	019	0	1	04	01	H0084_019_0	4	10	$0 Copayment	11	000000000000000000000010001011101000	000001110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	019	0	1	04	01	H0084_019_0	4	1	$40 Copayment	01	011110001101101000000000000000000011		2		1	40.00	40.00	2		2	2								
H0084	019	0	1	04	01	H0084_019_0	4	13	$o to $40 Copayment	01	000000000000000000000000000000000100		2		1	0.00	40.00	2		2	2								
H0084	021	0	1	04	01	H0084_021_0	4	5	$25 ot $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
H0084	021	0	1	04	01	H0084_021_0	4	10	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	021	0	1	04	01	H0084_021_0	4	11	$215 Copayment	01	000000000000000000000001000000000000		2		1	215.00	215.00	2		2	2								
H0084	021	0	1	04	01	H0084_021_0	4	12	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	021	0	1	04	01	H0084_021_0	4	13	$o to $40 Copayment	01	000000000000000000000000000000000100		2		1	0.00	40.00	2		2	2								
H0084	021	0	1	04	01	H0084_021_0	4	9	$150 Copayment	01	000000000000000000011000000000000000		2		1	150.00	150.00	2		2	2								
H0084	021	0	1	04	01	H0084_021_0	4	8	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	021	0	1	04	01	H0084_021_0	4	7	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	021	0	1	04	01	H0084_021_0	4	6	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	021	0	1	04	01	H0084_021_0	4	1	$40 Copayment	01	011110001101101000000000000000000011		2		1	40.00	40.00	2		2	2								
H0084	021	0	1	04	01	H0084_021_0	4	4	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	021	0	1	04	01	H0084_021_0	4	3	$25 Copayment	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H0084	021	0	1	04	01	H0084_021_0	4	2	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	021	0	1	04	01	H0084_021_0	4	14	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	022	0	1	04	01	H0084_022_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	022	0	1	04	01	H0084_022_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	022	0	1	04	01	H0084_022_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	022	0	1	04	01	H0084_022_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000001010100000010011100	2		1	0.00	0.00	2		2	2								
H0084	022	0	1	04	01	H0084_022_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	023	0	1	04	01	H0084_023_0	4	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	023	0	1	04	01	H0084_023_0	4	9	$250 Copayment	01	000000000000000000011000000000000000		2		1	250.00	250.00	2		2	2								
H0084	023	0	1	04	01	H0084_023_0	4	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	023	0	1	04	01	H0084_023_0	4	6	$15 to $40 Copayment	01	000000000010010000000100000000000000		2		1	15.00	40.00	2		2	2								
H0084	023	0	1	04	01	H0084_023_0	4	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	023	0	1	04	01	H0084_023_0	4	4	$15 Copayment	01	000000100000000000100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	023	0	1	04	01	H0084_023_0	4	3	40 % Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	023	0	1	04	01	H0084_023_0	4	2	$40  Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H0084	023	0	1	04	01	H0084_023_0	4	15	$14 Copayment	01	000000000000000100000000000000000000		2		1	14.00	14.00	2		2	2								
H0084	023	0	1	04	01	H0084_023_0	4	14	$340 to $3890 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	023	0	1	04	01	H0084_023_0	4	13	$0 to $35 Copayment	01	000000000000000000000000000000000100		2		1	0.00	35.00	2		2	2								
H0084	023	0	1	04	01	H0084_023_0	4	12	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	023	0	1	04	01	H0084_023_0	4	11	$160 Copayment	01	000000000000000000000001000000000000		2		1	160.00	160.00	2		2	2								
H0084	023	0	1	04	01	H0084_023_0	4	10	$0 Copayment	11	000000000000000000000010001011101000	000001110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	023	0	1	04	01	H0084_023_0	4	1	$35 Copayment	01	011100001101101000000000000000000011		2		1	35.00	35.00	2		2	2								
H0084	026	0	1	04	01	H0084_026_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	026	0	1	04	01	H0084_026_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	026	0	1	04	01	H0084_026_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	026	0	1	04	01	H0084_026_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000000010100000010011100	2		1	0.00	0.00	2		2	2								
H0084	026	0	1	04	01	H0084_026_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	027	0	1	04	01	H0084_027_0	4	11	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	027	0	1	04	01	H0084_027_0	4	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	027	0	1	04	01	H0084_027_0	4	6	$25 to $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
H0084	027	0	1	04	01	H0084_027_0	4	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	027	0	1	04	01	H0084_027_0	4	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	027	0	1	04	01	H0084_027_0	4	1	$50 Copayment	01	011100001101101000000000000000000011		2		1	50.00	50.00	2		2	2								
H0084	027	0	1	04	01	H0084_027_0	4	10	$150 Copayment	01	000000000000000000011000000000000000		2		1	150.00	150.00	2		2	2								
H0084	027	0	1	04	01	H0084_027_0	4	4	$25 Copayment	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H0084	027	0	1	04	01	H0084_027_0	4	12	$160 Copayment	01	000000000000000000000001000000000000		2		1	160.00	160.00	2		2	2								
H0084	027	0	1	04	01	H0084_027_0	4	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	027	0	1	04	01	H0084_027_0	4	14	$0 to $50 Copayment	01	000000000000000000000000000000000100		2		1	0.00	50.00	2		2	2								
H0084	027	0	1	04	01	H0084_027_0	4	15	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	027	0	1	04	01	H0084_027_0	4	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H0084	027	0	1	04	01	H0084_027_0	4	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	027	0	1	04	01	H0084_027_0	4	9	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	029	0	1	04	01	H0084_029_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	029	0	1	04	01	H0084_029_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000000010100000010011100	2		1	0.00	0.00	2		2	2								
H0084	029	0	1	04	01	H0084_029_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	029	0	1	04	01	H0084_029_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	029	0	1	04	01	H0084_029_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	030	0	1	04	01	H0084_030_0	4	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	030	0	1	04	01	H0084_030_0	4	4	$25 Copayment	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H0084	030	0	1	04	01	H0084_030_0	4	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H0084	030	0	1	04	01	H0084_030_0	4	15	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	030	0	1	04	01	H0084_030_0	4	14	$13 Copayment	01	000000000000000100000000000000000000		2		1	13.00	13.00	2		2	2								
H0084	030	0	1	04	01	H0084_030_0	4	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	030	0	1	04	01	H0084_030_0	4	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	030	0	1	04	01	H0084_030_0	4	6	$25 to $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
H0084	030	0	1	04	01	H0084_030_0	4	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	030	0	1	04	01	H0084_030_0	4	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	030	0	1	04	01	H0084_030_0	4	9	$15 Copayment	01	000000000000000000100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	030	0	1	04	01	H0084_030_0	4	1	$50 Copayment	01	011100001101101000000000000000000111		2		1	50.00	50.00	2		2	2								
H0084	030	0	1	04	01	H0084_030_0	4	10	$175 Copayment	01	000000000000000000011000000000000000		2		1	175.00	175.00	2		2	2								
H0084	030	0	1	04	01	H0084_030_0	4	11	$0 Copayment	11	000000000000000000000010001011101100	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	030	0	1	04	01	H0084_030_0	4	12	$200 Copayment	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H0084	031	0	1	04	01	H0084_031_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	031	0	1	04	01	H0084_031_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	031	0	1	04	01	H0084_031_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	031	0	1	04	01	H0084_031_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000000010100000010011100	2		1	0.00	0.00	2		2	2								
H0084	031	0	1	04	01	H0084_031_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	032	0	1	04	01	H0084_032_0	4	1	$50 Copayment	01	011100001101101000000000000000000111		2		1	50.00	50.00	2		2	2								
H0084	032	0	1	04	01	H0084_032_0	4	10	$175 Copayment	01	000000000000000000011000000000000000		2		1	175.00	175.00	2		2	2								
H0084	032	0	1	04	01	H0084_032_0	4	11	$0 Copayment	11	000000000000000000000010001011101100	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	032	0	1	04	01	H0084_032_0	4	12	$225 Copayment	01	000000000000000000000001000000000000		2		1	225.00	225.00	2		2	2								
H0084	032	0	1	04	01	H0084_032_0	4	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	032	0	1	04	01	H0084_032_0	4	14	$13 Copayment	01	000000000000000100000000000000000000		2		1	13.00	13.00	2		2	2								
H0084	032	0	1	04	01	H0084_032_0	4	15	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	032	0	1	04	01	H0084_032_0	4	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H0084	032	0	1	04	01	H0084_032_0	4	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	032	0	1	04	01	H0084_032_0	4	4	$25 Copayment	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H0084	032	0	1	04	01	H0084_032_0	4	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	032	0	1	04	01	H0084_032_0	4	6	$25 to $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
H0084	032	0	1	04	01	H0084_032_0	4	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	032	0	1	04	01	H0084_032_0	4	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	032	0	1	04	01	H0084_032_0	4	9	$15 Copayment	01	000000000000000000100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	033	0	1	04	01	H0084_033_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	033	0	1	04	01	H0084_033_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000000010100000010011100	2		1	0.00	0.00	2		2	2								
H0084	033	0	1	04	01	H0084_033_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	033	0	1	04	01	H0084_033_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	033	0	1	04	01	H0084_033_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	034	0	1	04	01	H0084_034_0	4	6	$25 to $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
H0084	034	0	1	04	01	H0084_034_0	4	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	034	0	1	04	01	H0084_034_0	4	4	$25 Copayment	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H0084	034	0	1	04	01	H0084_034_0	4	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	034	0	1	04	01	H0084_034_0	4	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H0084	034	0	1	04	01	H0084_034_0	4	15	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	034	0	1	04	01	H0084_034_0	4	14	$13 Copayment	01	000000000000000100000000000000000000		2		1	13.00	13.00	2		2	2								
H0084	034	0	1	04	01	H0084_034_0	4	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	034	0	1	04	01	H0084_034_0	4	12	$210 Copayment	01	000000000000000000000001000000000000		2		1	210.00	210.00	2		2	2								
H0084	034	0	1	04	01	H0084_034_0	4	11	$0 Copayment	11	000000000000000000000010001011101100	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	034	0	1	04	01	H0084_034_0	4	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	034	0	1	04	01	H0084_034_0	4	9	$15 Copayment	01	000000000000000000100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	034	0	1	04	01	H0084_034_0	4	10	$175 Copayment	01	000000000000000000011000000000000000		2		1	175.00	175.00	2		2	2								
H0084	034	0	1	04	01	H0084_034_0	4	1	$50 Copayment	01	011100001101101000000000000000000111		2		1	50.00	50.00	2		2	2								
H0084	034	0	1	04	01	H0084_034_0	4	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	035	0	1	04	01	H0084_035_0	3	3	$0 Copayment	11	000001000000000000000000000011100000	000000010000000010011100	2		1	0.00	0.00	2		2	2								
H0084	035	0	1	04	01	H0084_035_0	3	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	035	0	1	04	01	H0084_035_0	3	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	035	0	1	04	01	H0084_035_0	3	4	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	035	0	1	04	01	H0084_035_0	3	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	036	0	1	04	01	H0084_036_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	036	0	1	04	01	H0084_036_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	036	0	1	04	01	H0084_036_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000000010100000010011100	2		1	0.00	0.00	2		2	2								
H0084	036	0	1	04	01	H0084_036_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	036	0	1	04	01	H0084_036_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	037	0	1	04	01	H0084_037_0	4	7	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	037	0	1	04	01	H0084_037_0	4	1	$40 Copayment	01	011110001101101000000000000000000011		2		1	40.00	40.00	2		2	2								
H0084	037	0	1	04	01	H0084_037_0	4	10	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	037	0	1	04	01	H0084_037_0	4	11	$185 Copayment	01	000000000000000000000001000000000000		2		1	185.00	185.00	2		2	2								
H0084	037	0	1	04	01	H0084_037_0	4	12	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	037	0	1	04	01	H0084_037_0	4	9	$150 Copayment	01	000000000000000000011000000000000000		2		1	150.00	150.00	2		2	2								
H0084	037	0	1	04	01	H0084_037_0	4	8	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	037	0	1	04	01	H0084_037_0	4	6	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	037	0	1	04	01	H0084_037_0	4	5	$25 ot $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
H0084	037	0	1	04	01	H0084_037_0	4	4	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	037	0	1	04	01	H0084_037_0	4	3	$25 Copayment	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H0084	037	0	1	04	01	H0084_037_0	4	2	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	037	0	1	04	01	H0084_037_0	4	14	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	037	0	1	04	01	H0084_037_0	4	13	$0 to $40 Copayment	01	000000000000000000000000000000000100		2		1	0.00	40.00	2		2	2								
H0084	039	0	1	04	01	H0084_039_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	039	0	1	04	01	H0084_039_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	039	0	1	04	01	H0084_039_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	039	0	1	04	01	H0084_039_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	039	0	1	04	01	H0084_039_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000000010100000010011100	2		1	0.00	0.00	2		2	2								
H0084	040	0	1	04	01	H0084_040_0	4	1	$35 Copayment	01	011100001101101000000000000000000011		2		1	35.00	35.00	2		2	2								
H0084	040	0	1	04	01	H0084_040_0	4	10	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	040	0	1	04	01	H0084_040_0	4	11	$160 Copayment	01	000000000000000000000001000000000000		2		1	160.00	160.00	2		2	2								
H0084	040	0	1	04	01	H0084_040_0	4	12	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	040	0	1	04	01	H0084_040_0	4	13	$0 to $35 Copayment	01	000000000000000000000000000000000100		2		1	0.00	35.00	2		2	2								
H0084	040	0	1	04	01	H0084_040_0	4	14	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	040	0	1	04	01	H0084_040_0	4	2	$40  Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H0084	040	0	1	04	01	H0084_040_0	4	3	40 % Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	040	0	1	04	01	H0084_040_0	4	4	$15 Copayment	01	000000100000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	040	0	1	04	01	H0084_040_0	4	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	040	0	1	04	01	H0084_040_0	4	6	$15 to $40 Copayment	01	000000000010010000000100000000000000		2		1	15.00	40.00	2		2	2								
H0084	040	0	1	04	01	H0084_040_0	4	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	040	0	1	04	01	H0084_040_0	4	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	040	0	1	04	01	H0084_040_0	4	9	$250 Copayment	01	000000000000000000011000000000000000		2		1	250.00	250.00	2		2	2								
H0084	041	0	1	04	01	H0084_041_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000001010100000010011100	2		1	0.00	0.00	2		2	2								
H0084	041	0	1	04	01	H0084_041_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	041	0	1	04	01	H0084_041_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	041	0	1	04	01	H0084_041_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	041	0	1	04	01	H0084_041_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	042	0	1	04	01	H0084_042_0	4	9	$0 Copayment	11	000000000000000000000010001011101000	000001110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	042	0	1	04	01	H0084_042_0	4	11	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	042	0	1	04	01	H0084_042_0	4	10	$205 Copayment	01	000000000000000000000001000000000000		2		1	205.00	205.00	2		2	2								
H0084	042	0	1	04	01	H0084_042_0	4	1	$40 Copayment	01	011110001101101000000000000000000011		2		1	40.00	40.00	2		2	2								
H0084	042	0	1	04	01	H0084_042_0	4	8	$245 Copayment	01	000000000000000000011000000000000000		2		1	245.00	245.00	2		2	2								
H0084	042	0	1	04	01	H0084_042_0	4	7	$15 Copayment	01	000000000000000000100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	042	0	1	04	01	H0084_042_0	4	6	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	042	0	1	04	01	H0084_042_0	4	5	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	042	0	1	04	01	H0084_042_0	4	13	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	042	0	1	04	01	H0084_042_0	4	14	$12 Copayment	01	000000000000000100000000000000000000		2		1	12.00	12.00	2		2	2								
H0084	042	0	1	04	01	H0084_042_0	4	2	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	042	0	1	04	01	H0084_042_0	4	3	$20 Copayment	01	000000110000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	042	0	1	04	01	H0084_042_0	4	4	$20 to $40 Copayment	01	000000000010010000000100000000000000		2		1	20.00	40.00	2		2	2								
H0084	042	0	1	04	01	H0084_042_0	4	12	$0 to $40 Copayment	01	000000000000000000000000000000000100		2		1	0.00	40.00	2		2	2								
H0084	043	0	1	04	01	H0084_043_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000000010100000010011100	2		1	0.00	0.00	2		2	2								
H0084	043	0	1	04	01	H0084_043_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	043	0	1	04	01	H0084_043_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	043	0	1	04	01	H0084_043_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	043	0	1	04	01	H0084_043_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	044	0	1	04	01	H0084_044_0	4	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	044	0	1	04	01	H0084_044_0	4	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	044	0	1	04	01	H0084_044_0	4	6	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	044	0	1	04	01	H0084_044_0	4	5	$20 to $40 Copayment	01	000000000010010000000100000000000000		2		1	20.00	40.00	2		2	2								
H0084	044	0	1	04	01	H0084_044_0	4	4	$0 to $40 Copayment	01	000000000000000000000000000000000100		2		1	0.00	40.00	2		2	2								
H0084	044	0	1	04	01	H0084_044_0	4	3	$20 Copayment	01	000000110000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	044	0	1	04	01	H0084_044_0	4	9	$15 Copayment	01	000000000000000000100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	044	0	1	04	01	H0084_044_0	4	14	$12 Copayment	01	000000000000000100000000000000000000		2		1	12.00	12.00	2		2	2								
H0084	044	0	1	04	01	H0084_044_0	4	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	044	0	1	04	01	H0084_044_0	4	12	$250 Copayment	01	000000000000000000000001000000000000		2		1	250.00	250.00	2		2	2								
H0084	044	0	1	04	01	H0084_044_0	4	11	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	044	0	1	04	01	H0084_044_0	4	10	$245 Copayment	01	000000000000000000011000000000000000		2		1	245.00	245.00	2		2	2								
H0084	044	0	1	04	01	H0084_044_0	4	1	$40 Copayment	01	011110001101101000000000000000000011		2		1	40.00	40.00	2		2	2								
H0084	044	0	1	04	01	H0084_044_0	4	2	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	046	0	1	04	01	H0084_046_0	4	2	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	046	0	1	04	01	H0084_046_0	4	3	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	046	0	1	04	01	H0084_046_0	4	4	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H0084	046	0	1	04	01	H0084_046_0	4	5	$25 to $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
H0084	046	0	1	04	01	H0084_046_0	4	6	$25 Copayment	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H0084	046	0	1	04	01	H0084_046_0	4	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	046	0	1	04	01	H0084_046_0	4	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	046	0	1	04	01	H0084_046_0	4	9	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	046	0	1	04	01	H0084_046_0	4	1	$50 Copayment	01	011100001101101000000000000000000011		2		1	50.00	50.00	2		2	2								
H0084	046	0	1	04	01	H0084_046_0	4	10	$250 Copayment	01	000000000000000000011000000000000000		2		1	250.00	250.00	2		2	2								
H0084	046	0	1	04	01	H0084_046_0	4	11	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	046	0	1	04	01	H0084_046_0	4	12	$160 Copayment	01	000000000000000000000001000000000000		2		1	160.00	160.00	2		2	2								
H0084	046	0	1	04	01	H0084_046_0	4	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	046	0	1	04	01	H0084_046_0	4	14	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	046	0	1	04	01	H0084_046_0	4	15	$0 to $50 Copayment	01	000000000000000000000000000000000100		2		1	0.00	50.00	2		2	2								
H0084	047	0	1	04	01	H0084_047_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	047	0	1	04	01	H0084_047_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	047	0	1	04	01	H0084_047_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000001010100000010011100	2		1	0.00	0.00	2		2	2								
H0084	047	0	1	04	01	H0084_047_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	047	0	1	04	01	H0084_047_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	048	0	1	04	01	H0084_048_0	4	14	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	048	0	1	04	01	H0084_048_0	4	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	048	0	1	04	01	H0084_048_0	4	12	$160 Copayment	01	000000000000000000000001000000000000		2		1	160.00	160.00	2		2	2								
H0084	048	0	1	04	01	H0084_048_0	4	11	$0 Copayment	11	000000000000000000000010001011101000	000001110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	048	0	1	04	01	H0084_048_0	4	10	$250 Copayment	01	000000000000000000011000000000000000		2		1	250.00	250.00	2		2	2								
H0084	048	0	1	04	01	H0084_048_0	4	1	$35 Copayment	01	011100001101101000000000000000000011		2		1	35.00	35.00	2		2	2								
H0084	048	0	1	04	01	H0084_048_0	4	2	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	048	0	1	04	01	H0084_048_0	4	9	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	048	0	1	04	01	H0084_048_0	4	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	048	0	1	04	01	H0084_048_0	4	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	048	0	1	04	01	H0084_048_0	4	6	$0 to $35 Copayment	01	000000000000000000000000000000000100		2		1	0.00	35.00	2		2	2								
H0084	048	0	1	04	01	H0084_048_0	4	3	$20 Copayment	01	000000110000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	048	0	1	04	01	H0084_048_0	4	4	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H0084	048	0	1	04	01	H0084_048_0	4	5	$20 to $40 Copayment	01	000000000010010000000100000000000000		2		1	20.00	40.00	2		2	2								
H0084	049	0	1	04	01	H0084_049_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	049	0	1	04	01	H0084_049_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000000010100000010011100	2		1	0.00	0.00	2		2	2								
H0084	049	0	1	04	01	H0084_049_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	049	0	1	04	01	H0084_049_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	049	0	1	04	01	H0084_049_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	050	0	1	04	01	H0084_050_0	4	1	$35 Copayment	01	011100001101101000000000000000000011		2		1	35.00	35.00	2		2	2								
H0084	050	0	1	04	01	H0084_050_0	4	10	$250 Copayment	01	000000000000000000011000000000000000		2		1	250.00	250.00	2		2	2								
H0084	050	0	1	04	01	H0084_050_0	4	11	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	050	0	1	04	01	H0084_050_0	4	12	$180 Copayment	01	000000000000000000000001000000000000		2		1	180.00	180.00	2		2	2								
H0084	050	0	1	04	01	H0084_050_0	4	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	050	0	1	04	01	H0084_050_0	4	14	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	050	0	1	04	01	H0084_050_0	4	9	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	050	0	1	04	01	H0084_050_0	4	3	$20 Copayment	01	000000110000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	050	0	1	04	01	H0084_050_0	4	4	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H0084	050	0	1	04	01	H0084_050_0	4	5	$20 to $40 Copayment	01	000000000010010000000100000000000000		2		1	20.00	40.00	2		2	2								
H0084	050	0	1	04	01	H0084_050_0	4	6	$0 to $35 Copayment	01	000000000000000000000000000000000100		2		1	0.00	35.00	2		2	2								
H0084	050	0	1	04	01	H0084_050_0	4	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	050	0	1	04	01	H0084_050_0	4	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	050	0	1	04	01	H0084_050_0	4	2	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	051	0	1	04	01	H0084_051_0	3	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	051	0	1	04	01	H0084_051_0	3	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	051	0	1	04	01	H0084_051_0	3	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	051	0	1	04	01	H0084_051_0	3	4	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	051	0	1	04	01	H0084_051_0	3	3	$0 Copayment	11	000001000000000000000000000011100000	000000010000000010011100	2		1	0.00	0.00	2		2	2								
H0084	052	0	1	04	01	H0084_052_0	4	1	$50 Copayment	01	011100001101101000000000000000000011		2		1	50.00	50.00	2		2	2								
H0084	052	0	1	04	01	H0084_052_0	4	9	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	052	0	1	04	01	H0084_052_0	4	11	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	052	0	1	04	01	H0084_052_0	4	12	$185 Copayment	01	000000000000000000000001000000000000		2		1	185.00	185.00	2		2	2								
H0084	052	0	1	04	01	H0084_052_0	4	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	052	0	1	04	01	H0084_052_0	4	14	$0 to $50 Copayment	01	000000000000000000000000000000000100		2		1	0.00	50.00	2		2	2								
H0084	052	0	1	04	01	H0084_052_0	4	15	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	052	0	1	04	01	H0084_052_0	4	2	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	052	0	1	04	01	H0084_052_0	4	3	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	052	0	1	04	01	H0084_052_0	4	4	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H0084	052	0	1	04	01	H0084_052_0	4	5	$25 to $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
H0084	052	0	1	04	01	H0084_052_0	4	6	$25 Copayment	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H0084	052	0	1	04	01	H0084_052_0	4	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	052	0	1	04	01	H0084_052_0	4	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	052	0	1	04	01	H0084_052_0	4	10	$250 Copayment	01	000000000000000000011000000000000000		2		1	250.00	250.00	2		2	2								
H0084	053	0	1	04	01	H0084_053_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	053	0	1	04	01	H0084_053_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	053	0	1	04	01	H0084_053_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	053	0	1	04	01	H0084_053_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000001010100000010011100	2		1	0.00	0.00	2		2	2								
H0084	053	0	1	04	01	H0084_053_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	054	0	1	04	01	H0084_054_0	4	1	$40 Copayment	01	011110001101101000000000000000000011		2		1	40.00	40.00	2		2	2								
H0084	054	0	1	04	01	H0084_054_0	4	10	$230 Copayment	01	000000000000000000000001000000000000		2		1	230.00	230.00	2		2	2								
H0084	054	0	1	04	01	H0084_054_0	4	11	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	054	0	1	04	01	H0084_054_0	4	12	$0 to $40 Copayment	01	000000000000000000000000000000000100		2		1	0.00	40.00	2		2	2								
H0084	054	0	1	04	01	H0084_054_0	4	13	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	054	0	1	04	01	H0084_054_0	4	14	$12 Copayment	01	000000000000000100000000000000000000		2		1	12.00	12.00	2		2	2								
H0084	054	0	1	04	01	H0084_054_0	4	9	$0 Copayment	11	000000000000000000000010001011101000	000001110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	054	0	1	04	01	H0084_054_0	4	3	$20 Copayment	01	000000110000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	054	0	1	04	01	H0084_054_0	4	4	$20 to $40 Copayment	01	000000000010010000000100000000000000		2		1	20.00	40.00	2		2	2								
H0084	054	0	1	04	01	H0084_054_0	4	5	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	054	0	1	04	01	H0084_054_0	4	6	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	054	0	1	04	01	H0084_054_0	4	7	$15 Copayment	01	000000000000000000100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	054	0	1	04	01	H0084_054_0	4	8	$245 Copayment	01	000000000000000000011000000000000000		2		1	245.00	245.00	2		2	2								
H0084	054	0	1	04	01	H0084_054_0	4	2	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	055	0	1	04	01	H0084_055_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	055	0	1	04	01	H0084_055_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	055	0	1	04	01	H0084_055_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	055	0	1	04	01	H0084_055_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000000010100000010011100	2		1	0.00	0.00	2		2	2								
H0084	055	0	1	04	01	H0084_055_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	056	0	1	04	01	H0084_056_0	4	1	$40 Copayment	01	011110001101101000000000000000000011		2		1	40.00	40.00	2		2	2								
H0084	056	0	1	04	01	H0084_056_0	4	10	$250 Copayment	01	000000000000000000000001000000000000		2		1	250.00	250.00	2		2	2								
H0084	056	0	1	04	01	H0084_056_0	4	11	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	056	0	1	04	01	H0084_056_0	4	12	$0 to $40 Copayment	01	000000000000000000000000000000000100		2		1	0.00	40.00	2		2	2								
H0084	056	0	1	04	01	H0084_056_0	4	13	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	056	0	1	04	01	H0084_056_0	4	14	$12 Copayment	01	000000000000000100000000000000000000		2		1	12.00	12.00	2		2	2								
H0084	056	0	1	04	01	H0084_056_0	4	9	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	056	0	1	04	01	H0084_056_0	4	3	$20 Copayment	01	000000110000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	056	0	1	04	01	H0084_056_0	4	4	$20 to $40 Copayment	01	000000000010010000000100000000000000		2		1	20.00	40.00	2		2	2								
H0084	056	0	1	04	01	H0084_056_0	4	5	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	056	0	1	04	01	H0084_056_0	4	6	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	056	0	1	04	01	H0084_056_0	4	7	$15 Copayment	01	000000000000000000100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	056	0	1	04	01	H0084_056_0	4	8	$245 Copayment	01	000000000000000000011000000000000000		2		1	245.00	245.00	2		2	2								
H0084	056	0	1	04	01	H0084_056_0	4	2	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	057	0	1	04	01	H0084_057_0	4	1	$50 Copayment	01	011100001101101000000000000000000011		2		1	50.00	50.00	2		2	2								
H0084	057	0	1	04	01	H0084_057_0	4	9	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	057	0	1	04	01	H0084_057_0	4	11	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	057	0	1	04	01	H0084_057_0	4	12	$205 Copayment	01	000000000000000000000001000000000000		2		1	205.00	205.00	2		2	2								
H0084	057	0	1	04	01	H0084_057_0	4	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	057	0	1	04	01	H0084_057_0	4	14	$0 to $50 Copayment	01	000000000000000000000000000000000100		2		1	0.00	50.00	2		2	2								
H0084	057	0	1	04	01	H0084_057_0	4	15	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	057	0	1	04	01	H0084_057_0	4	2	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	057	0	1	04	01	H0084_057_0	4	3	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	057	0	1	04	01	H0084_057_0	4	4	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H0084	057	0	1	04	01	H0084_057_0	4	5	$25 to $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
H0084	057	0	1	04	01	H0084_057_0	4	6	$25 Copayment	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H0084	057	0	1	04	01	H0084_057_0	4	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	057	0	1	04	01	H0084_057_0	4	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	057	0	1	04	01	H0084_057_0	4	10	$250 Copayment	01	000000000000000000011000000000000000		2		1	250.00	250.00	2		2	2								
H0084	058	0	1	04	01	H0084_058_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	058	0	1	04	01	H0084_058_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	058	0	1	04	01	H0084_058_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	058	0	1	04	01	H0084_058_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000001010100000010011100	2		1	0.00	0.00	2		2	2								
H0084	058	0	1	04	01	H0084_058_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	059	0	1	04	01	H0084_059_0	4	10	$245 Copayment	01	000000000000000000011000000000000000		2		1	245.00	245.00	2		2	2								
H0084	059	0	1	04	01	H0084_059_0	4	11	$0 Copayment	11	000000000000000000000010001011101000	000001110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	059	0	1	04	01	H0084_059_0	4	12	$220 Copayment	01	000000000000000000000001000000000000		2		1	220.00	220.00	2		2	2								
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H0084	059	0	1	04	01	H0084_059_0	4	14	$12 Copayment	01	000000000000000100000000000000000000		2		1	12.00	12.00	2		2	2								
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H0084	059	0	1	04	01	H0084_059_0	4	3	$20 Copayment	01	000000110000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	059	0	1	04	01	H0084_059_0	4	4	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	059	0	1	04	01	H0084_059_0	4	5	$20 to $40 Copayment	01	000000000010010000000100000000000000		2		1	20.00	40.00	2		2	2								
H0084	059	0	1	04	01	H0084_059_0	4	6	$0 to $40 Copayment	01	000000000000000000000000000000000100		2		1	0.00	40.00	2		2	2								
H0084	059	0	1	04	01	H0084_059_0	4	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	059	0	1	04	01	H0084_059_0	4	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	059	0	1	04	01	H0084_059_0	4	9	$15 Copayment	01	000000000000000000100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	059	0	1	04	01	H0084_059_0	4	1	$40 Copayment	01	011110001101101000000000000000000011		2		1	40.00	40.00	2		2	2								
H0084	060	0	1	04	01	H0084_060_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0084	060	0	1	04	01	H0084_060_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0084	060	0	1	04	01	H0084_060_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0084	060	0	1	04	01	H0084_060_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0084	060	0	1	04	01	H0084_060_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000000010100000010011100	2		1	0.00	0.00	2		2	2								
H0084	061	0	1	04	01	H0084_061_0	4	5	$20 to $40 Copayment	01	000000000010010000000100000000000000		2		1	20.00	40.00	2		2	2								
H0084	061	0	1	04	01	H0084_061_0	4	6	$0 to $40 Copayment	01	000000000000000000000000000000000100		2		1	0.00	40.00	2		2	2								
H0084	061	0	1	04	01	H0084_061_0	4	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	061	0	1	04	01	H0084_061_0	4	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	061	0	1	04	01	H0084_061_0	4	4	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	061	0	1	04	01	H0084_061_0	4	3	$20 Copayment	01	000000110000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	061	0	1	04	01	H0084_061_0	4	2	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	061	0	1	04	01	H0084_061_0	4	14	$12 Copayment	01	000000000000000100000000000000000000		2		1	12.00	12.00	2		2	2								
H0084	061	0	1	04	01	H0084_061_0	4	9	$15 Copayment	01	000000000000000000100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	061	0	1	04	01	H0084_061_0	4	12	$250 Copayment	01	000000000000000000000001000000000000		2		1	250.00	250.00	2		2	2								
H0084	061	0	1	04	01	H0084_061_0	4	11	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	061	0	1	04	01	H0084_061_0	4	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	061	0	1	04	01	H0084_061_0	4	1	$40 Copayment	01	011110001101101000000000000000000011		2		1	40.00	40.00	2		2	2								
H0084	061	0	1	04	01	H0084_061_0	4	10	$245 Copayment	01	000000000000000000011000000000000000		2		1	245.00	245.00	2		2	2								
H0084	063	0	1	04	01	H0084_063_0	4	9	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	063	0	1	04	01	H0084_063_0	4	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	063	0	1	04	01	H0084_063_0	4	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	063	0	1	04	01	H0084_063_0	4	6	$25 Copayment	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H0084	063	0	1	04	01	H0084_063_0	4	4	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H0084	063	0	1	04	01	H0084_063_0	4	5	$25 to $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
H0084	063	0	1	04	01	H0084_063_0	4	3	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	063	0	1	04	01	H0084_063_0	4	2	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	063	0	1	04	01	H0084_063_0	4	15	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	063	0	1	04	01	H0084_063_0	4	14	$0 to $50 Copayment	01	000000000000000000000000000000000100		2		1	0.00	50.00	2		2	2								
H0084	063	0	1	04	01	H0084_063_0	4	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	063	0	1	04	01	H0084_063_0	4	12	$190 Copayment	01	000000000000000000000001000000000000		2		1	190.00	190.00	2		2	2								
H0084	063	0	1	04	01	H0084_063_0	4	11	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	063	0	1	04	01	H0084_063_0	4	10	$250 Copayment	01	000000000000000000011000000000000000		2		1	250.00	250.00	2		2	2								
H0084	063	0	1	04	01	H0084_063_0	4	1	$50 Copayment	01	011100001101101000000000000000000011		2		1	50.00	50.00	2		2	2								
H0084	064	0	1	04	01	H0084_064_0	4	11	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	064	0	1	04	01	H0084_064_0	4	10	$220 Copayment	01	000000000000000000000001000000000000		2		1	220.00	220.00	2		2	2								
H0084	064	0	1	04	01	H0084_064_0	4	1	$20 Copayment	01	011100011101101000000000000000000011		2		1	20.00	20.00	2		2	2								
H0084	064	0	1	04	01	H0084_064_0	4	12	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	064	0	1	04	01	H0084_064_0	4	13	$5 to $40 Copayment	01	000000000010010000000100000000000000		2		1	5.00	40.00	2		2	2								
H0084	064	0	1	04	01	H0084_064_0	4	14	$0 to $20 Copayment	01	000000000000000000000000000000000100		2		1	0.00	20.00	2		2	2								
H0084	064	0	1	04	01	H0084_064_0	4	5	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	064	0	1	04	01	H0084_064_0	4	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	064	0	1	04	01	H0084_064_0	4	4	$5 Copayment	01	000000100000000000000000000000000000		2		1	5.00	5.00	2		2	2								
H0084	064	0	1	04	01	H0084_064_0	4	9	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	064	0	1	04	01	H0084_064_0	4	8	$100 Copayment	01	000000000000000000011000000000000000		2		1	100.00	100.00	2		2	2								
H0084	064	0	1	04	01	H0084_064_0	4	7	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H0084	064	0	1	04	01	H0084_064_0	4	6	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	064	0	1	04	01	H0084_064_0	4	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H0084	065	0	1	04	01	H0084_065_0	4	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	065	0	1	04	01	H0084_065_0	4	4	$5 Copayment	01	000000100000000000000000000000000000		2		1	5.00	5.00	2		2	2								
H0084	065	0	1	04	01	H0084_065_0	4	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	065	0	1	04	01	H0084_065_0	4	6	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	065	0	1	04	01	H0084_065_0	4	7	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	065	0	1	04	01	H0084_065_0	4	8	$100 Copayment	01	000000000000000000011000000000000000		2		1	100.00	100.00	2		2	2								
H0084	065	0	1	04	01	H0084_065_0	4	9	$0 Copayment	11	000000000000000000000010001011101000	000001110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	065	0	1	04	01	H0084_065_0	4	1	$15 Copayment	01	011100001101101100100000000000000011		2		1	15.00	15.00	2		2	2								
H0084	065	0	1	04	01	H0084_065_0	4	10	$160 Copayment	01	000000000000000000000001000000000000		2		1	160.00	160.00	2		2	2								
H0084	065	0	1	04	01	H0084_065_0	4	11	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	065	0	1	04	01	H0084_065_0	4	12	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	065	0	1	04	01	H0084_065_0	4	13	$5 to $40 Copayment	01	000000000010010000000100000000000000		2		1	5.00	40.00	2		2	2								
H0084	065	0	1	04	01	H0084_065_0	4	14	$0 to $15 Copayment	01	000000000000000000000000000000000100		2		1	0.00	15.00	2		2	2								
H0084	065	0	1	04	01	H0084_065_0	4	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H0084	066	0	1	04	01	H0084_066_0	4	1	$15 Copayment	01	011100001101101100100000000000000011		2		1	15.00	15.00	2		2	2								
H0084	066	0	1	04	01	H0084_066_0	4	10	$195 Copayment	01	000000000000000000000001000000000000		2		1	195.00	195.00	2		2	2								
H0084	066	0	1	04	01	H0084_066_0	4	11	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0084	066	0	1	04	01	H0084_066_0	4	12	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0084	066	0	1	04	01	H0084_066_0	4	13	$5 to $40 Copayment	01	000000000010010000000100000000000000		2		1	5.00	40.00	2		2	2								
H0084	066	0	1	04	01	H0084_066_0	4	14	$0 to $15 Copayment	01	000000000000000000000000000000000100		2		1	0.00	15.00	2		2	2								
H0084	066	0	1	04	01	H0084_066_0	4	9	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H0084	066	0	1	04	01	H0084_066_0	4	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0084	066	0	1	04	01	H0084_066_0	4	4	$5 Copayment	01	000000100000000000000000000000000000		2		1	5.00	5.00	2		2	2								
H0084	066	0	1	04	01	H0084_066_0	4	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0084	066	0	1	04	01	H0084_066_0	4	6	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0084	066	0	1	04	01	H0084_066_0	4	7	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0084	066	0	1	04	01	H0084_066_0	4	8	$100 Copayment	01	000000000000000000011000000000000000		2		1	100.00	100.00	2		2	2								
H0084	066	0	1	04	01	H0084_066_0	4	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H0104	010	1	1	04	01	H0104_010_1	12	2	Ambulance Services	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H0104	010	1	1	04	01	H0104_010_1	12	1	Part B - General	11	011111111111111111111110111111111111	000000100000000010100000	2		2			2		2	1			30	30				
H0104	010	2	1	04	01	H0104_010_2	12	1	Part B - General	11	011111111111111111111110111111111111	000000100000000010100000	2		2			2		2	1			30	30				
H0104	010	2	1	04	01	H0104_010_2	12	2	Ambulance Services	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H0104	010	3	1	04	01	H0104_010_3	10	2	Ambulance Services	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H0104	010	3	1	04	01	H0104_010_3	10	1	Part B - General	11	011111111111111111111110111111111111	000000100000000010100000	2		2			2		2	1			30	30				
H0104	010	4	1	04	01	H0104_010_4	11	2	Ambulance Services	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H0104	010	4	1	04	01	H0104_010_4	11	1	Part B - General	11	011111111111111111111110111111111111	000000100000000010100000	2		2			2		2	1			30	30				
H0104	010	5	1	04	01	H0104_010_5	10	1	Part B - General	11	011111111111111111111110111111111111	000000100000000010100000	2		2			2		2	1			30	30				
H0104	010	5	1	04	01	H0104_010_5	10	2	Ambulance Services	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H0104	011	1	1	04	01	H0104_011_1	10	1	Part B - General	11	011111111111111111111110111111111111	000000100000000010000000	2		2			2		2	1			30	30				
H0104	011	1	1	04	01	H0104_011_1	10	2	Ambulance	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H0104	011	2	1	04	01	H0104_011_2	9	1	Part B - General	11	011111111111111111111110111111111111	000000100000000010000000	2		2			2		2	1			30	30				
H0104	011	2	1	04	01	H0104_011_2	9	2	Ambulance	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H0104	011	3	1	04	01	H0104_011_3	12	2	Ambulance	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H0104	011	3	1	04	01	H0104_011_3	12	1	Part B - General	11	011111111111111111111110111111111111	000000100000000010000000	2		2			2		2	1			30	30				
H0104	011	4	1	04	01	H0104_011_4	9	1	Part B - General	11	011111111111111111111110111111111111	000000100000000010000000	2		2			2		2	1			30	30				
H0104	011	4	1	04	01	H0104_011_4	9	2	Ambulance	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H0104	011	5	1	04	01	H0104_011_5	9	2	Ambulance	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H0104	011	5	1	04	01	H0104_011_5	9	1	Part B - General	11	011111111111111111111110111111111111	000000100000000010000000	2		2			2		2	1			30	30				
H0104	011	6	1	04	01	H0104_011_6	10	1	Part B - General	11	011111111111111111111110111111111111	000000100000000010000000	2		2			2		2	1			30	30				
H0104	011	6	1	04	01	H0104_011_6	10	2	Ambulance	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
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H0104	801	0	1	04	01	H0104_801_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H0104	801	0	1	04	01	H0104_801_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H0104	802	0	1	04	01	H0104_802_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H0104	802	0	1	04	01	H0104_802_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H0104	802	0	1	04	01	H0104_802_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H0104	804	0	1	04	01	H0104_804_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H0104	804	0	1	04	01	H0104_804_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H0104	804	0	1	04	01	H0104_804_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H0248	001	0	1	04	01	H0248_001_0	7	4		01	000000000000000000000000111000000000		2		2			2		2	1			40	40				
H0248	001	0	1	04	01	H0248_001_0	7	3		01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H0248	001	0	1	04	01	H0248_001_0	7	2		01	000000000000000001000000000000000000		2		2			2		2	1			20	25				
H0248	001	0	1	04	01	H0248_001_0	7	1		11	011111111111111110111100000001101101	000010001000000100010000	2		2			2		2	1			25	25				
H0248	001	0	1	04	01	H0248_001_0	7	9		01	000000000000000000000000000010000000		2		2			2		2	1			0	25				
H0248	001	0	1	04	01	H0248_001_0	7	6		11	000000000000000000000010000000000010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H0248	001	0	1	04	01	H0248_001_0	7	7		10		000000000110000010100000	2		2			2		2	1			50	50				
H0248	001	0	1	04	01	H0248_001_0	7	8		01	000000000000000000000000000000010000		2		2			2		2	1			20	20				
H0248	001	0	1	04	01	H0248_001_0	7	5		01	000000000000000000000000000100000000		2		2			2		2	1			0	20				
H0294	001	0	1	04	01	H0294_001_0	6	4	$0 Copayment	11	000001000000000000000000000011100000	000001010100000010011100	2		1	0.00	0.00	2		2	2								
H0294	001	0	1	04	01	H0294_001_0	6	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0294	001	0	1	04	01	H0294_001_0	6	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0294	001	0	1	04	01	H0294_001_0	6	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0294	001	0	1	04	01	H0294_001_0	6	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0294	002	0	1	04	01	H0294_002_0	6	1	$40 Copayment	01	011110001101101000000000000000000011		2		1	40.00	40.00	2		2	2								
H0294	002	0	1	04	01	H0294_002_0	6	10	$0 Copayment	11	000000000000000000000010001011101000	000001110000000010000100	2		1	0.00	0.00	2		2	2								
H0294	002	0	1	04	01	H0294_002_0	6	11	$160 Copayment	01	000000000000000000000001000000000000		2		1	160.00	160.00	2		2	2								
H0294	002	0	1	04	01	H0294_002_0	6	12	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0294	002	0	1	04	01	H0294_002_0	6	13	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0294	002	0	1	04	01	H0294_002_0	6	14	$14 Copayment	01	000000000000000100000000000000000000		2		1	14.00	14.00	2		2	2								
H0294	002	0	1	04	01	H0294_002_0	6	9	$150 Copayment	01	000000000000000000011000000000000000		2		1	150.00	150.00	2		2	2								
H0294	002	0	1	04	01	H0294_002_0	6	3	$20 Copayment	01	000000110000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0294	002	0	1	04	01	H0294_002_0	6	4	$20 to $40 Copayment	01	000000000010010000000100000000000000		2		1	20.00	40.00	2		2	2								
H0294	002	0	1	04	01	H0294_002_0	6	5	$0 to $40 Copayment	01	000000000000000000000000000000000100		2		1	0.00	40.00	2		2	2								
H0294	002	0	1	04	01	H0294_002_0	6	6	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0294	002	0	1	04	01	H0294_002_0	6	7	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0294	002	0	1	04	01	H0294_002_0	6	8	$15 Copayment	01	000000000000000000100000000000000000		2		1	15.00	15.00	2		2	2								
H0294	002	0	1	04	01	H0294_002_0	6	2	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0294	004	0	1	04	01	H0294_004_0	6	9	$250 Copayment	01	000000000000000000011000000000000000		2		1	250.00	250.00	2		2	2								
H0294	004	0	1	04	01	H0294_004_0	6	1	$40 Copayment	01	011110001101101000000000000000000011		2		1	40.00	40.00	2		2	2								
H0294	004	0	1	04	01	H0294_004_0	6	10	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H0294	004	0	1	04	01	H0294_004_0	6	11	$185 Copayment	01	000000000000000000000001000000000000		2		1	185.00	185.00	2		2	2								
H0294	004	0	1	04	01	H0294_004_0	6	12	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0294	004	0	1	04	01	H0294_004_0	6	13	$0 to $40 Copayment	01	000000000000000000000000000000000100		2		1	0.00	40.00	2		2	2								
H0294	004	0	1	04	01	H0294_004_0	6	14	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0294	004	0	1	04	01	H0294_004_0	6	2	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0294	004	0	1	04	01	H0294_004_0	6	3	$25 Copayment	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H0294	004	0	1	04	01	H0294_004_0	6	4	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0294	004	0	1	04	01	H0294_004_0	6	5	$25 to $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
H0294	004	0	1	04	01	H0294_004_0	6	6	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0294	004	0	1	04	01	H0294_004_0	6	7	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0294	004	0	1	04	01	H0294_004_0	6	8	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H0294	006	0	1	04	01	H0294_006_0	6	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0294	006	0	1	04	01	H0294_006_0	6	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0294	006	0	1	04	01	H0294_006_0	6	3	$0 Copayment	11	000001000000000000000000000011100000	000000010000000010011100	2		1	0.00	0.00	2		2	2								
H0294	006	0	1	04	01	H0294_006_0	6	4	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0294	006	0	1	04	01	H0294_006_0	6	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0294	007	0	1	04	01	H0294_007_0	6	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H0294	007	0	1	04	01	H0294_007_0	6	4	$0 Copayment	11	000001000000000000000000000011100000	000000010100000010011100	2		1	0.00	0.00	2		2	2								
H0294	007	0	1	04	01	H0294_007_0	6	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H0294	007	0	1	04	01	H0294_007_0	6	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H0294	007	0	1	04	01	H0294_007_0	6	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H0294	008	0	1	04	01	H0294_008_0	6	2	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H0294	008	0	1	04	01	H0294_008_0	6	3	$20 Copayment	01	000000110000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H0294	008	0	1	04	01	H0294_008_0	6	4	$20 to $40 Copayment	01	000000000010010000000100000000000000		2		1	20.00	40.00	2		2	2								
H0294	008	0	1	04	01	H0294_008_0	6	5	$0 to $40 Copayment	01	000000000000000000000000000000000100		2		1	0.00	40.00	2		2	2								
H0294	008	0	1	04	01	H0294_008_0	6	6	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H0294	008	0	1	04	01	H0294_008_0	6	7	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H0294	008	0	1	04	01	H0294_008_0	6	13	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H0294	008	0	1	04	01	H0294_008_0	6	9	$150 Copayment	01	000000000000000000011000000000000000		2		1	150.00	150.00	2		2	2								
H0294	008	0	1	04	01	H0294_008_0	6	12	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H0294	008	0	1	04	01	H0294_008_0	6	11	$160 Copayment	01	000000000000000000000001000000000000		2		1	160.00	160.00	2		2	2								
H0294	008	0	1	04	01	H0294_008_0	6	10	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H0294	008	0	1	04	01	H0294_008_0	6	1	$40 Copayment	01	011110001101101000000000000000000011		2		1	40.00	40.00	2		2	2								
H0294	008	0	1	04	01	H0294_008_0	6	8	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H0317	001	0	1	04	01	H0317_001_0	5	1		11	011110111111111111111000000001111101	000001000000000100000000	2		2			2		2	1			20	20				
H0317	001	0	1	04	01	H0317_001_0	5	2		01	000001000000000000000000111000000000		2		2			2		2	1			25	25				
H0317	001	0	1	04	01	H0317_001_0	5	3		01	000000000000000000000100000000000000		2		2			2		2	1			15	15				
H0317	001	0	1	04	01	H0317_001_0	5	4		01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H0317	001	0	1	04	01	H0317_001_0	5	5		01	000000000000000000000000000110000000		2		2			2		2	1			0	20				
H0317	001	0	1	04	01	H0317_001_0	5	8		10		000000000000000000110000	2		2			2		2	1			50	80				
H0317	001	0	1	04	01	H0317_001_0	5	7		10		000000000110000010000000	2		2			2		2	1			50	50				
H0317	001	0	1	04	01	H0317_001_0	5	6		11	000000000000000000000010000000000010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H0317	004	0	1	04	01	H0317_004_0	5	1		01	000010110111110000000000000000001001		2		1	40.00	40.00	2		2	2								
H0317	004	0	1	04	01	H0317_004_0	5	10		11	000000000000000000000010000001100010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H0317	004	0	1	04	01	H0317_004_0	5	11		10		000000000110000010110000	2		2			2		2	1			50	50				
H0317	004	0	1	04	01	H0317_004_0	5	12		01	000000000000000000000000000000010000		2		2			2		2	1			20	20				
H0317	004	0	1	04	01	H0317_004_0	5	13		01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H0317	004	0	1	04	01	H0317_004_0	5	9		01	000000000000000000000000000100000000		2		2			2		2	1			0	20				
H0317	004	0	1	04	01	H0317_004_0	5	2		11	000001000000000000000000111000000000	000000000000000100000000	2		2			2		2	1			30	30				
H0317	004	0	1	04	01	H0317_004_0	5	3		01	000000001000001100000000000000000000		2		1	40.00	100.00	2		2	1			30	30				
H0317	004	0	1	04	01	H0317_004_0	5	4		01	011100000000000010100000000000000000		2		1	40.00	100.00	2		2	2								
H0317	004	0	1	04	01	H0317_004_0	5	14		01	000000000000000000000000000000000100		2		1	40.00	40.00	2		2	1			30	30				
H0317	004	0	1	04	01	H0317_004_0	5	6		01	000000000000000000010000000000000000		2		1	35.00	100.00	2		2	2								
H0317	004	0	1	04	01	H0317_004_0	5	7		01	000000000000000000001100000000000000		2		1	100.00	100.00	2		2	2								
H0317	004	0	1	04	01	H0317_004_0	5	8		01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H0317	004	0	1	04	01	H0317_004_0	5	5		01	000000000000000001000000000000000000		2		1	40.00	40.00	2		2	1			20	20				
H0317	006	0	1	04	01	H0317_006_0	5	9		01	000000000000000000000000111000000000		2		2			2		2	1			25	25				
H0317	006	0	1	04	01	H0317_006_0	5	7		01	000000000000000000001100000000000000		2		1	100.00	100.00	2		2	2								
H0317	006	0	1	04	01	H0317_006_0	5	6		01	000000000000000000010000000000000000		2		1	35.00	100.00	2		2	2								
H0317	006	0	1	04	01	H0317_006_0	5	5		01	000000000000000001000000000000000000		2		1	40.00	40.00	2		2	1			20	20				
H0317	006	0	1	04	01	H0317_006_0	5	4		01	011100000000000010100000000000000000		2		1	40.00	100.00	2		2	2								
H0317	006	0	1	04	01	H0317_006_0	5	3		01	000000001000001100000000000000000000		2		1	40.00	100.00	2		2	1			30	30				
H0317	006	0	1	04	01	H0317_006_0	5	2		11	000001000000000000000000000000000000	000000000000000100000000	2		2			2		2	1			30	30				
H0317	006	0	1	04	01	H0317_006_0	5	15		01	000000000000000000000000000000000100		2		1	40.00	40.00	2		2	1			30	30				
H0317	006	0	1	04	01	H0317_006_0	5	14		01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H0317	006	0	1	04	01	H0317_006_0	5	13		01	000000000000000000000000000000010000		2		2			2		2	1			20	20				
H0317	006	0	1	04	01	H0317_006_0	5	12		10		000000000110000010000000	2		2			2		2	1			50	50				
H0317	006	0	1	04	01	H0317_006_0	5	11		11	000000000000000000000010000001100010	000000100000000000000000	2		1	0.00	0.00	2		2	2								
H0317	006	0	1	04	01	H0317_006_0	5	10		01	000000000000000000000000000100000000		2		2			2		2	1			0	20				
H0317	006	0	1	04	01	H0317_006_0	5	1		11	000010110111110000000000000000001001	000000000000000000001000	2		1	40.00	40.00	2		2	2								
H0317	006	0	1	04	01	H0317_006_0	5	8		01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H0317	007	0	1	04	01	H0317_007_0	4	13		01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H0317	007	0	1	04	01	H0317_007_0	4	8		01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H0317	007	0	1	04	01	H0317_007_0	4	7		01	000000000000000000000100000000000000		2		1	100.00	100.00	2		2	2								
H0317	007	0	1	04	01	H0317_007_0	4	6		01	000000000000000000010000000000000000		2		1	35.00	35.00	2		2	1			30	30				
H0317	007	0	1	04	01	H0317_007_0	4	5		01	000000000000000001000000000000000000		2		1	40.00	40.00	2		2	1			20	20				
H0317	007	0	1	04	01	H0317_007_0	4	1		01	000010110111110000000000000000001001		2		1	40.00	40.00	2		2	2								
H0317	007	0	1	04	01	H0317_007_0	4	10		11	000000000000000000000010000001100010	000000100000000010001000	2		1	0.00	0.00	2		2	2								
H0317	007	0	1	04	01	H0317_007_0	4	11		10		000000000110000000110000	2		2			2		2	1			50	50				
H0317	007	0	1	04	01	H0317_007_0	4	12		01	000000000000000000000000000000010000		2		2			2		2	1			20	20				
H0317	007	0	1	04	01	H0317_007_0	4	9		01	000000000000000000000000000100000000		2		2			2		2	1			0	20				
H0317	007	0	1	04	01	H0317_007_0	4	14		01	000000000000000000000000000000000100		2		1	40.00	40.00	2		2	1			30	30				
H0317	007	0	1	04	01	H0317_007_0	4	15		01	000000000000000000000000000000000100		2		1	40.00	40.00	2		2	1			30	30				
H0317	007	0	1	04	01	H0317_007_0	4	2		11	000001000000000000001000111000000000	000000000000000100000000	2		2			2		2	1			30	30				
H0317	007	0	1	04	01	H0317_007_0	4	3		01	000000001000001100000000000000000000		2		1	40.00	100.00	2		2	1			30	30				
H0317	007	0	1	04	01	H0317_007_0	4	4		01	011100000000000010100000000000000000		2		1	40.00	100.00	2		2	2								
H0319	001	0	1	04	01	H0319_001_0	7	5	Group 5	01	000000000000000100000000000010000000		2		2			2		2	1			0	30				
H0319	001	0	1	04	01	H0319_001_0	7	4	Group 4	10		000000010000000000000000	2		2			2		2	1			75	75				
H0319	001	0	1	04	01	H0319_001_0	7	3	Group 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H0319	001	0	1	04	01	H0319_001_0	7	2	Group 2	11	000000000000000000000000000000000010	000000000000000000110101	2		1	0.00	0.00	2		2	2								
H0319	001	0	1	04	01	H0319_001_0	7	1	Group 1	11	011111111111111011111111111001111101	000001100000000000001010	2		2			2		2	1			30	30				
H0620	002	0	1	04	01	H0620_002_0	6	1	Group 1	11	011111111111111011111111111001111101	000001100000000000001010	2		2			2		2	1			30	30				
H0620	002	0	1	04	01	H0620_002_0	6	4	Group 4	01	000000000000000100000000000010000000		2		2			2		2	1			0	30				
H0620	002	0	1	04	01	H0620_002_0	6	3	Group 3	10		000000010000000000000000	2		2			2		2	1			75	75				
H0620	002	0	1	04	01	H0620_002_0	6	2	Group 2	11	000000000000000000000000000100000010	000000000100000000110101	2		1	0.00	0.00	2		2	2								
H0623	001	0	1	04	01	H0623_001_0	6	5		01	000000000000000000000000000000010000		2		2			2		2	1			20	40				
H0623	001	0	1	04	01	H0623_001_0	6	4		10		000000000100000010000000	2		2			2		2	1			50	50				
H0623	001	0	1	04	01	H0623_001_0	6	3		11	000000000000000000000010000000000010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H0623	001	0	1	04	01	H0623_001_0	6	2		01	000000000000000000000001000100000000		2		2			2		2	1			20	20				
H0623	001	0	1	04	01	H0623_001_0	6	6		01	000000000000000000000000000010000000		2		2			2		2	1			0	50				
H0623	001	0	1	04	01	H0623_001_0	6	1		11	011111111111111111111100111001101101	000000000000000100000000	2		2			2		2	1			40	40				
H0623	009	0	1	04	01	H0623_009_0	4	5		01	000000000000000000000000000000010000		2		2			2		2	1			20	30				
H0623	009	0	1	04	01	H0623_009_0	4	6		01	000000000000000000000000000010000000		2		2			2		2	1			0	50				
H0623	009	0	1	04	01	H0623_009_0	4	4		10		000000000110000010000000	2		2			2		2	1			50	50				
H0623	009	0	1	04	01	H0623_009_0	4	3		11	000000000000000000000010000000000010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H0623	009	0	1	04	01	H0623_009_0	4	2		01	000000000000000000000001111100000000		2		2			2		2	1			20	20				
H0623	009	0	1	04	01	H0623_009_0	4	1		11	011111111111111111111100000001101101	000000000000000100000000	2		2			2		2	1			30	30				
H0623	011	0	1	04	01	H0623_011_0	7	6		01	000000000000000000000000000010000000		2		2			2		2	1			0	50				
H0623	011	0	1	04	01	H0623_011_0	7	5		01	000000000000000000000000000000010000		2		2			2		2	1			20	40				
H0623	011	0	1	04	01	H0623_011_0	7	4		10		000000000100000010000000	2		2			2		2	1			50	50				
H0623	011	0	1	04	01	H0623_011_0	7	3		11	000000000000000000000010000000000010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H0623	011	0	1	04	01	H0623_011_0	7	2		01	000000000000000000000001000100000000		2		2			2		2	1			20	20				
H0623	011	0	1	04	01	H0623_011_0	7	1		11	011111111111111111111100111001101101	000000000000000100000000	2		2			2		2	1			40	40				
H0710	001	0	1	04	01	H0710_001_0	7	1	Group 1	11	011111111111111011111111111001111101	000001100000000000001000	2		2			2		2	1			30	30				
H0710	001	0	1	04	01	H0710_001_0	7	2	Group 2	11	000000000000000000000000000000000010	000000000100000000000100	2		1	0.00	0.00	2		2	2								
H0710	001	0	1	04	01	H0710_001_0	7	5	Group 5	01	000000000000000100000000000010000000		2		2			2		2	1			0	30				
H0710	001	0	1	04	01	H0710_001_0	7	4	Group 4	10		000000010000000000000000	2		2			2		2	1			75	75				
H0710	001	0	1	04	01	H0710_001_0	7	3	Group 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H0879	001	0	1	04	01	H0879_001_0	3	2	Ambulance	01	000000000000000000000001000000000000		2		1	250.00	250.00	2		2	2								
H0879	001	0	1	04	01	H0879_001_0	3	1	Services	11	011111111111111111111110110101111010	000000100000000000000000	2		2			2		2	1			30	30				
H0879	001	0	1	04	01	H0879_001_0	3	5	Preventive	01	000000000000000000000000000010000000		2		2			2		2	1			0	0				
H0879	001	0	1	04	01	H0879_001_0	3	4	Eye/Hearing	01	000000000000000000000000000000000101		2		2			2		2	1			20	20				
H0879	001	0	1	04	01	H0879_001_0	3	3	Diabetes	01	000000000000000000000000001000000000		2		2			2		2	1			20	20				
H0879	002	0	1	04	01	H0879_002_0	3	2	Diabetic Supplies	01	000000000000000000000000001000000000		2		2			2		2	1			20	20				
H0879	002	0	1	04	01	H0879_002_0	3	3	Eye Exams	01	000000000000000000000000000000000100		2		2			2		2	1			30	30				
H0879	002	0	1	04	01	H0879_002_0	3	4	Services	01	011111111111111111111100000000000000		2		2			2		2	1			50	50				
H0879	002	0	1	04	01	H0879_002_0	3	5	DME	01	000000000000000000000000110000000000		2		2			2		2	1			50	50				
H0879	002	0	1	04	01	H0879_002_0	3	6	ESRD	01	000000000000000000000000000100000000		2		2			2		2	1			50	50				
H0879	002	0	1	04	01	H0879_002_0	3	7	Part B	11	000000000000000000000010000000010000	000000100000000000000000	2		2			2		2	1			30	30				
H0879	002	0	1	04	01	H0879_002_0	3	8	Preventive	01	000000000000000000000000000010000000		2		2			2		2	1			0	0				
H0879	002	0	1	04	01	H0879_002_0	3	13	eye wear	01	000000000000000000000000000000000010		2		2			2		2	1			30	30				
H0879	002	0	1	04	01	H0879_002_0	3	9	Hearing	01	000000000000000000000000000000000001		2		2			2		2	1			30	30				
H0879	002	0	1	04	01	H0879_002_0	3	11	Education	01	000000000000000000000000000001100000		2		2			2		2	1			30	30				
H0879	002	0	1	04	01	H0879_002_0	3	10	Blood	01	000000000000000000000010000000000000		2		2			2		2	1			30	30				
H0879	002	0	1	04	01	H0879_002_0	3	1	Ambulance	01	000000000000000000000001000000000000		2		1	350.00	350.00	2		2	2								
H0879	002	0	1	04	01	H0879_002_0	3	12	Comp Dental	01	000000000000000000000000000000001000		2		2			2		2	1			30	30				
H1108	001	0	1	04	01	H1108_001_0	6	1	Group 1	11	011111111111111011111111111001111101	000001100000000000001010	2		2			2		2	1			30	30				
H1108	001	0	1	04	01	H1108_001_0	6	2	Group 2	11	000000000000000000000000000000000010	000000000000000000000101	2		1	0.00	0.00	2		2	2								
H1108	001	0	1	04	01	H1108_001_0	6	5	Group 5	01	000000000000000100000000000010000000		2		2			2		2	1			0	30				
H1108	001	0	1	04	01	H1108_001_0	6	3	Group 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H1108	001	0	1	04	01	H1108_001_0	6	4	Group 4	10		000000010000000000000000	2		2			2		2	1			75	75				
H1108	002	0	1	04	01	H1108_002_0	7	1	Group 1	11	011111111111111011111111111001111101	000001100000000000001000	2		2			2		2	1			30	30				
H1108	002	0	1	04	01	H1108_002_0	7	2	Group 2	01	000000000000000100000000000010000000		2		2			2		2	1			0	30				
H1108	002	0	1	04	01	H1108_002_0	7	4	Group 4	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H1108	002	0	1	04	01	H1108_002_0	7	5	Group 5	11	000000000000000000000000000000000010	000000000100000010110100	2		1	0.00	0.00	2		2	2								
H1108	002	0	1	04	01	H1108_002_0	7	3	Group 3	10		000000010000000000000000	2		2			2		2	1			75	75				
H1110	001	0	1	04	01	H1110_001_0	8	2	Tier 2	01	000000000000000000000001000000000000		2		1	250.00	250.00	2		2	2								
H1110	001	0	1	04	01	H1110_001_0	8	3	Tier 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H1110	001	0	1	04	01	H1110_001_0	8	4	Tier 4	10		000000000000100010000100	2		2			2		2	2								
H1110	001	0	1	04	01	H1110_001_0	8	1	Tier 1	11	011111111111111111111110111011111111	000000000001000000001010	2		2			2		2	1			35	35				
H1110	801	0	1	04	01	H1110_801_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H1110	801	0	1	04	01	H1110_801_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H1110	801	0	1	04	01	H1110_801_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H1110	802	0	1	04	01	H1110_802_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H1110	802	0	1	04	01	H1110_802_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H1110	802	0	1	04	01	H1110_802_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H1110	805	0	2	04	01	H1110_805_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H1110	805	0	2	04	01	H1110_805_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H1110	805	0	2	04	01	H1110_805_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H1110	806	0	2	04	01	H1110_806_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H1110	806	0	2	04	01	H1110_806_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H1110	806	0	2	04	01	H1110_806_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H1266	001	0	1	09	04	H1266_001_0	9	2		01	000000000000000000000000101000000000		2		2			2		2	1			20	20				
H1266	001	0	1	09	04	H1266_001_0	9	4		10		000000000110000010110000	2		2			2		2	1			50	50				
H1266	001	0	1	09	04	H1266_001_0	9	3		11	000000000000000000000010000010000000	000000100000000100000000	2		1	0.00	0.00	2		2	2								
H1266	001	0	1	09	04	H1266_001_0	9	1		01	000000000000000100000000000000000000		2		2			2		2	1			0	25				
H1266	002	0	1	09	04	H1266_002_0	5	3		11	000000000000000000000010000000000000	000000100000000100000000	2		1	0.00	0.00	2		2	2								
H1266	002	0	1	09	04	H1266_002_0	5	5		01	000000000000000000000000000010000000		2		2			2		2	1			0	0				
H1266	002	0	1	09	04	H1266_002_0	5	2		01	000000000000000000000000101000000000		2		2			2		2	1			20	20				
H1266	002	0	1	09	04	H1266_002_0	5	4		10		000000000110000010000000	2		2			2		2	1			50	50				
H1266	002	0	1	09	04	H1266_002_0	5	1		01	000000000000000100000000000000000000		2		2			2		2	1			0	20				
H1266	003	0	1	09	04	H1266_003_0	6	2		01	000000000000000000000000101000000000		2		2			2		2	1			20	20				
H1266	003	0	1	09	04	H1266_003_0	6	3		11	000000000000000000000010000010000000	000000100000000100000000	2		1	0.00	0.00	2		2	2								
H1266	003	0	1	09	04	H1266_003_0	6	1		01	000000000000000100000000000000000000		2		2			2		2	1			0	25				
H1266	003	0	1	09	04	H1266_003_0	6	4		10		000000000110000010000000	2		2			2		2	1			50	50				
H1291	001	0	1	09	04	H1291_001_0	7	10		01	000000000000000000001000000000000000		2		1	195.00	195.00	2		2	2								
H1291	001	0	1	09	04	H1291_001_0	7	1		01	000010000000000000000000111100010000		2		2			2		2	1			20	20				
H1291	001	0	1	09	04	H1291_001_0	7	11		01	000000000000000000000100000000000000		2		2			2		2	1			25	25				
H1291	001	0	1	09	04	H1291_001_0	7	9		01	000000000000000000010000000000000000		2		2			2		2	1			20	25				
H1291	001	0	1	09	04	H1291_001_0	7	8		01	000000000000000001000000000000000000		2		1	40.00	40.00	2		2	1			20	20				
H1291	001	0	1	09	04	H1291_001_0	7	7		01	000000000000000010000000000000000000		2		1	75.00	75.00	2		1	1	2		20	25		1	15.00	40.00
H1291	001	0	1	09	04	H1291_001_0	7	12		01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H1291	001	0	1	09	04	H1291_001_0	7	13		10		000000000110000010110000	2		2			2		2	1			50	50				
H1291	001	0	1	09	04	H1291_001_0	7	14		01	000000000000000000000000000000000100		2		1	0.00	40.00	2		2	2								
H1291	001	0	1	09	04	H1291_001_0	7	15		01	000000000000000000000000000000000010		2		1	25.00	25.00	2		2	2								
H1291	001	0	1	09	04	H1291_001_0	7	2		11	000001000000000000000010000011100000	000000100000000100001000	2		1	0.00	0.00	2		2	2								
H1291	001	0	1	09	04	H1291_001_0	7	3		01	011100110000000000000000000000000000		2		1	15.00	15.00	2		2	2								
H1291	001	0	1	09	04	H1291_001_0	7	4		01	000000001000001000100000000000000000		2		1	15.00	50.00	2		2	2								
H1291	001	0	1	09	04	H1291_001_0	7	5		01	000000000111110000000000000000001001		2		1	40.00	40.00	2		2	2								
H1291	001	0	1	09	04	H1291_001_0	7	6		01	000000000000000100000000000000000000		2		1	0.00	50.00	2		2	1			20	25				
H1291	003	0	1	09	04	H1291_003_0	5	3		01	000000000000000100000000000000000100		2		2			2		2	1			0	20				
H1291	003	0	1	09	04	H1291_003_0	5	2		11	000001000000000000000010000011100000	000000100000000100001000	2		1	0.00	0.00	2		2	2								
H1291	003	0	1	09	04	H1291_003_0	5	1		01	011110111111111011111101111100011011		2		2			2		2	1			20	20				
H1291	003	0	1	09	04	H1291_003_0	5	4		10		000000000110000010000000	2		2			2		2	1			50	50				
H1302	001	0	1	04	01	H1302_001_0	6	4	30% Coinsurance	01	000011000010010111111100111100011000		2		2			2		2	1			30	30				
H1302	001	0	1	04	01	H1302_001_0	6	3	Ambulance $150 Copayment	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H1302	001	0	1	04	01	H1302_001_0	6	2	$40 Copay	11	011100111101101000000000000000000101	000000000000000000001000	2		1	40.00	40.00	2		2	2								
H1302	001	0	1	04	01	H1302_001_0	6	1	No Cost Share	11	000000000000000000000010000011100010	000000100000000010000000	2		2			2		2	1			0	0				
H1302	001	0	1	04	01	H1302_001_0	6	5	$100 Maximum Eyewear	10		000000000000000000000100	1	100.00	2			2		2	2								
H1302	004	0	1	04	01	H1302_004_0	5	7	$100.00 Vision Plan Maximum	10		000000000000000000000100	1	100.00	2			2		2	1			0	0				
H1302	004	0	1	04	01	H1302_004_0	5	6	25% Coinsurance	11	000010000010010111100110000000001000	000000100000000000000000	2		2			2		2	1			25	25				
H1302	004	0	1	04	01	H1302_004_0	5	5	20% Coinsurance	01	000001000000000000011000111100000000		2		2			2		2	1			20	20				
H1302	004	0	1	04	01	H1302_004_0	5	4	30% Coinsurance	01	000000000000000000000000000000010000		2		2			2		2	1			30	30				
H1302	004	0	1	04	01	H1302_004_0	5	3	Ambulance $150 Copayment	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H1302	004	0	1	04	01	H1302_004_0	5	1	No Cost Share	11	000000000000000000000000000011100010	000000000000000010000000	2		2			2		2	1			0	0				
H1302	004	0	1	04	01	H1302_004_0	5	2	$30 Copay	11	011100111101101000000000000000000101	000000000000000000001000	2		1	30.00	30.00	2		2	2								
H1302	006	0	1	04	01	H1302_006_0	6	1	No Cost Share	11	000000000000000000000010000011100010	000000100000000010000000	2		2			2		2	1			0	0				
H1302	006	0	1	04	01	H1302_006_0	6	2	$40 Copay	11	011100111101101000000000000000000101	000000000000000000001000	2		1	40.00	40.00	2		2	2								
H1302	006	0	1	04	01	H1302_006_0	6	3	Ambulance $150 Copayment	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H1302	006	0	1	04	01	H1302_006_0	6	4	30% Coinsurance	01	000011000010010111111100111100011000		2		2			2		2	1			30	30				
H1302	006	0	1	04	01	H1302_006_0	6	5	$100 Maximum Eyewear	10		000000000000000000000100	1	100.00	2			2		2	2								
H1303	001	0	1	04	01	H1303_001_0	7	7	Group 7	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H1303	001	0	1	04	01	H1303_001_0	7	8	Group 8	01	000000000010010000000100000000000000		2		1	35.00	45.00	2		2	2								
H1303	001	0	1	04	01	H1303_001_0	7	9	Group 9	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H1303	001	0	1	04	01	H1303_001_0	7	1	Group 1	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H1303	001	0	1	04	01	H1303_001_0	7	10	Group 10	11	000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2	2								
H1303	001	0	1	04	01	H1303_001_0	7	11	Group 11	01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H1303	001	0	1	04	01	H1303_001_0	7	6	Group 6	01	000010000000000000000000000000000000		2		1	75.00	75.00	2		2	2								
H1303	001	0	1	04	01	H1303_001_0	7	13	Group 13	01	000000000000100000000000000000000000		2		1	25.00	40.00	2		2	2								
H1303	001	0	1	04	01	H1303_001_0	7	14	Group 14	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H1303	001	0	1	04	01	H1303_001_0	7	2	Group 2	11	011100011101001000000000000000001101	000001000000000000001010	2		1	40.00	40.00	2		2	2								
H1303	001	0	1	04	01	H1303_001_0	7	3	Group 3	11	000000000000000011011000011001110010	000000000001000100000000	2		2			2		2	1			30	30				
H1303	001	0	1	04	01	H1303_001_0	7	4	Group 4	01	000000000000000100000000000000000000		2		1	15.00	15.00	2		2	1			30	30				
H1303	001	0	1	04	01	H1303_001_0	7	5	Group 5	01	000000000000000000100000000000000000		2		1	21.00	21.00	2		2	2								
H1303	001	0	1	04	01	H1303_001_0	7	12	Group 12	01	000001000000000000000000100000000000		2		2			2		2	1			50	50				
H1304	001	0	1	04	01	H1304_001_0	8	1	$35	11	011100111111111000000100000000001001	000000000000000000001000	2		1	35.00	35.00	2		2	2								
H1304	001	0	1	04	01	H1304_001_0	8	10	$225	01	000000000000000000001000000000000000		2		1	225.00	225.00	2		2	2								
H1304	001	0	1	04	01	H1304_001_0	8	9	$0 to $225	01	000000000000000000010000000000000000		2		1	0.00	225.00	2		2	2								
H1304	001	0	1	04	01	H1304_001_0	8	8	$0 to $35	01	000000000000000000000000000000000100		2		1	0.00	35.00	2		2	2								
H1304	001	0	1	04	01	H1304_001_0	8	7	$0 - no cost sharing	11	000010000000000100000010001011100010	000000100000000110000100	2		1	0.00	0.00	2		2	2								
H1304	001	0	1	04	01	H1304_001_0	8	6	10% to 20%	01	000000000000000000000000000000010000		2		2			2		2	1			10	20				
H1304	001	0	1	04	01	H1304_001_0	8	5	30% coinsurance	01	000000000000000010000000110000000000		2		2			2		2	1			30	30				
H1304	001	0	1	04	01	H1304_001_0	8	4	20%	01	000001000000000001100000000000000000		2		2			2		2	1			20	20				
H1304	001	0	1	04	01	H1304_001_0	8	3	End-Stage Renal Disease	01	000000000000000000000000000100000000		2		2			2		2	1			10	10				
H1304	001	0	1	04	01	H1304_001_0	8	2	$150 copay	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H1304	001	0	1	04	01	H1304_001_0	8	11	$500 Preventive Dental	10		000000000000000000100000	2		2			2		2	1			20	20				
H1304	002	0	1	04	01	H1304_002_0	12	1	$35	11	011100111111111000000100000000001001	000000000000000000001000	2		1	35.00	35.00	2		2	2								
H1304	002	0	1	04	01	H1304_002_0	12	8	$0 to $35	01	000000000000000000000000000000000100		2		1	0.00	35.00	2		2	2								
H1304	002	0	1	04	01	H1304_002_0	12	7	$0 - no cost sharing	11	000010000000000100000010001011100010	000000100000000110000100	2		1	0.00	0.00	2		2	2								
H1304	002	0	1	04	01	H1304_002_0	12	6	10% to 20%	01	000000000000000000000000000000010000		2		2			2		2	1			10	20				
H1304	002	0	1	04	01	H1304_002_0	12	5	30% coinsurance	01	000000000000000010000000110000000000		2		2			2		2	1			30	30				
H1304	002	0	1	04	01	H1304_002_0	12	9	$0 to $225	01	000000000000000000010000000000000000		2		1	0.00	225.00	2		2	2								
H1304	002	0	1	04	01	H1304_002_0	12	3	End-Stage Renal Disease	01	000000000000000000000000000100000000		2		2			2		2	1			10	10				
H1304	002	0	1	04	01	H1304_002_0	12	2	$150 copay	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H1304	002	0	1	04	01	H1304_002_0	12	11	$500 Preventive Dental	10		000000000000000000100000	2		2			2		2	1			50	50				
H1304	002	0	1	04	01	H1304_002_0	12	10	$225	01	000000000000000000001000000000000000		2		1	225.00	225.00	2		2	2								
H1304	002	0	1	04	01	H1304_002_0	12	4	20%	01	000001000000000001100000000000000000		2		2			2		2	1			20	20				
H1304	004	0	1	04	01	H1304_004_0	10	6	0% to 10%	01	000000000000000000000000000000010000		2		2			2		2	1			0	10				
H1304	004	0	1	04	01	H1304_004_0	10	7	$0 - no cost sharing	11	000010000000000100000010001011100010	000000100000000110000100	2		1	0.00	0.00	2		2	2								
H1304	004	0	1	04	01	H1304_004_0	10	8	$0 to $25	01	000000000000000000000000000000000100		2		1	0.00	25.00	2		2	2								
H1304	004	0	1	04	01	H1304_004_0	10	9	$0 to $200	01	000000000000000000010000000000000000		2		1	0.00	200.00	2		2	2								
H1304	004	0	1	04	01	H1304_004_0	10	1	$25	11	011100111111111000000100000000001001	000000000000000000001000	2		1	25.00	25.00	2		2	2								
H1304	004	0	1	04	01	H1304_004_0	10	10	$200	01	000000000000000000001000000000000000		2		1	200.00	200.00	2		2	2								
H1304	004	0	1	04	01	H1304_004_0	10	11	$500 Preventive Dental	10		000000000000000000100000	2		2			2		2	1			20	20				
H1304	004	0	1	04	01	H1304_004_0	10	12	30%	01	000000000000000010000000000000000000		2		2			2		2	1			30	30				
H1304	004	0	1	04	01	H1304_004_0	10	2	$150 copay	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H1304	004	0	1	04	01	H1304_004_0	10	3	End-Stage Renal Disease	01	000000000000000000000000000100000000		2		2			2		2	1			10	10				
H1304	004	0	1	04	01	H1304_004_0	10	4	10%	01	000001000000000000100000000000000000		2		2			2		2	1			10	10				
H1304	004	0	1	04	01	H1304_004_0	10	5	20% coinsurance	01	000000000000000001000000110000000000		2		2			2		2	1			20	20				
H1304	008	0	1	04	01	H1304_008_0	8	9	$0 to $225	01	000000000000000000010000000000000000		2		1	0.00	225.00	2		2	2								
H1304	008	0	1	04	01	H1304_008_0	8	2	$150 copay	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H1304	008	0	1	04	01	H1304_008_0	8	11	$500 Preventive Dental	10		000000000000000000100000	2		2			2		2	1			20	20				
H1304	008	0	1	04	01	H1304_008_0	8	10	$225	01	000000000000000000001000000000000000		2		1	225.00	225.00	2		2	2								
H1304	008	0	1	04	01	H1304_008_0	8	1	$35	11	011100111111111000000100000000001001	000000000000000000001000	2		1	35.00	35.00	2		2	2								
H1304	008	0	1	04	01	H1304_008_0	8	3	End-Stage Renal Disease	01	000000000000000000000000000100000000		2		2			2		2	1			10	10				
H1304	008	0	1	04	01	H1304_008_0	8	8	$0 to $35	01	000000000000000000000000000000000100		2		1	0.00	35.00	2		2	2								
H1304	008	0	1	04	01	H1304_008_0	8	7	$0 - no cost sharing	11	000010000000000100000010001011100010	000000100000000110000100	2		1	0.00	0.00	2		2	2								
H1304	008	0	1	04	01	H1304_008_0	8	6	10% to 20%	01	000000000000000000000000000000010000		2		2			2		2	1			10	20				
H1304	008	0	1	04	01	H1304_008_0	8	5	30% coinsurance	01	000000000000000010000000110000000000		2		2			2		2	1			30	30				
H1304	008	0	1	04	01	H1304_008_0	8	4	20%	01	000001000000000001100000000000000000		2		2			2		2	1			20	20				
H1304	009	0	1	04	01	H1304_009_0	10	10	$225	01	000000000000000000001000000000000000		2		1	225.00	225.00	2		2	2								
H1304	009	0	1	04	01	H1304_009_0	10	11	$500 Preventive Dental	10		000000000000000000100000	2		2			2		2	1			50	50				
H1304	009	0	1	04	01	H1304_009_0	10	2	$150 copay	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H1304	009	0	1	04	01	H1304_009_0	10	3	End-Stage Renal Disease	01	000000000000000000000000000100000000		2		2			2		2	1			10	10				
H1304	009	0	1	04	01	H1304_009_0	10	4	20%	01	000001000000000001100000000000000000		2		2			2		2	1			20	20				
H1304	009	0	1	04	01	H1304_009_0	10	1	$35	11	011100111111111000000100000000001001	000000000000000000001000	2		1	35.00	35.00	2		2	2								
H1304	009	0	1	04	01	H1304_009_0	10	6	10% to 20%	01	000000000000000000000000000000010000		2		2			2		2	1			10	20				
H1304	009	0	1	04	01	H1304_009_0	10	7	$0 - no cost sharing	11	000010000000000100000010001011100010	000000100000000110000100	2		1	0.00	0.00	2		2	2								
H1304	009	0	1	04	01	H1304_009_0	10	8	$0 to $35	01	000000000000000000000000000000000100		2		1	0.00	35.00	2		2	2								
H1304	009	0	1	04	01	H1304_009_0	10	9	$0 to $225	01	000000000000000000010000000000000000		2		1	0.00	225.00	2		2	2								
H1304	009	0	1	04	01	H1304_009_0	10	5	30% coinsurance	01	000000000000000010000000110000000000		2		2			2		2	1			30	30				
H1304	010	0	1	04	01	H1304_010_0	12	3	End-Stage Renal Disease	01	000000000000000000000000000100000000		2		2			2		2	1			10	10				
H1304	010	0	1	04	01	H1304_010_0	12	2	$150 copay	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H1304	010	0	1	04	01	H1304_010_0	12	12	30%	01	000000000000000010000000000000000000		2		2			2		2	1			30	30				
H1304	010	0	1	04	01	H1304_010_0	12	11	$500 Preventive Dental	10		000000000000000000100000	2		2			2		2	1			20	20				
H1304	010	0	1	04	01	H1304_010_0	12	10	$200	01	000000000000000000001000000000000000		2		1	200.00	200.00	2		2	2								
H1304	010	0	1	04	01	H1304_010_0	12	1	$25	11	011100111111111000000100000000001001	000000000000000000001000	2		1	25.00	25.00	2		2	2								
H1304	010	0	1	04	01	H1304_010_0	12	9	$0 to $200	01	000000000000000000010000000000000000		2		1	0.00	200.00	2		2	2								
H1304	010	0	1	04	01	H1304_010_0	12	8	$0 to $25	01	000000000000000000000000000000000100		2		1	0.00	25.00	2		2	2								
H1304	010	0	1	04	01	H1304_010_0	12	7	$0 - no cost sharing	11	000010000000000100000010001011100010	000000100000000110000100	2		1	0.00	0.00	2		2	2								
H1304	010	0	1	04	01	H1304_010_0	12	6	0% to 10%	01	000000000000000000000000000000010000		2		2			2		2	1			0	10				
H1304	010	0	1	04	01	H1304_010_0	12	4	10%	01	000001000000000000100000000000000000		2		2			2		2	1			10	10				
H1304	010	0	1	04	01	H1304_010_0	12	5	20% coinsurance	01	000000000000000001000000110000000000		2		2			2		2	1			20	20				
H1304	803	0	1	04	01	H1304_803_0	6	3	0% to 20%	01	000000000000000100000000000000000000		2		2			2		2	1			0	20				
H1304	803	0	1	04	01	H1304_803_0	6	4	20%	01	011110111101101011111101111101111101		2		2			2		2	1			20	20				
H1304	803	0	1	04	01	H1304_803_0	6	1	$0	01	000001000000000000000010000010000010		2		1	0.00	0.00	2		2	2								
H1304	803	0	1	04	01	H1304_803_0	6	2	35%	01	000000000010010000000000000000000000		2		2			2		2	1			40	40				
H1304	804	0	1	04	01	H1304_804_0	6	1	$0	01	000001000000000000000010000010000010		2		1	0.00	0.00	2		2	2								
H1304	804	0	1	04	01	H1304_804_0	6	4	20%	01	011110111101101011111101111101111101		2		2			2		2	1			20	20				
H1304	804	0	1	04	01	H1304_804_0	6	3	0% to 20%	01	000000000000000100000000000000000000		2		2			2		2	1			0	20				
H1304	804	0	1	04	01	H1304_804_0	6	2	35%	01	000000000010010000000000000000000000		2		2			2		2	1			40	40				
H1365	001	0	1	04	01	H1365_001_0	8	1	Group 1	11	011110011111111011011110110010001111	000000100000000100001000	2		2			2		2	1			30	30				
H1365	001	0	1	04	01	H1365_001_0	8	2	Group 2	01	000001000000000000000000001100010000		2		2			2		2	1			20	20				
H1365	001	0	1	04	01	H1365_001_0	8	5	Group 5	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H1365	001	0	1	04	01	H1365_001_0	8	4	Group 4	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H1365	001	0	1	04	01	H1365_001_0	8	3	Group 3	11	000000000000000100100000000001100000	000000000001000000000000	2		2			2		2	2								
H1365	002	0	1	04	01	H1365_002_0	7	5	Group 5	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H1365	002	0	1	04	01	H1365_002_0	7	1	Group 1	11	011110011111111011011110110010001111	000000100000000100001000	2		2			2		2	1			30	30				
H1365	002	0	1	04	01	H1365_002_0	7	2	Group 2	01	000001000000000000000000001100010000		2		2			2		2	1			20	20				
H1365	002	0	1	04	01	H1365_002_0	7	4	Group 4	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H1365	002	0	1	04	01	H1365_002_0	7	3	Group 3	11	000000000000000100100000000001100000	000000000001000000000000	2		2			2		2	2								
H1365	003	0	1	04	01	H1365_003_0	7	2	Group 2	01	000001000000000000000000001100010000		2		2			2		2	1			20	20				
H1365	003	0	1	04	01	H1365_003_0	7	1	Group 1	11	011110011111111011011110110010001111	000000100000000100001000	2		2			2		2	1			30	30				
H1365	003	0	1	04	01	H1365_003_0	7	3	Group 3	11	000000000000000100100000000001100000	000000000001000000000000	2		2			2		2	2								
H1365	003	0	1	04	01	H1365_003_0	7	4	Group 4	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H1365	003	0	1	04	01	H1365_003_0	7	5	Group 5	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H1365	802	0	1	04	01	H1365_802_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H1365	802	0	1	04	01	H1365_802_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H1365	802	0	1	04	01	H1365_802_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H1417	001	0	1	04	01	H1417_001_0	3	6	Eye Wear	01	000000000000000000000000000000000010		2		1	0.00	0.00	2		2	2								
H1417	001	0	1	04	01	H1417_001_0	3	5	ASC	01	000000000000000000011000000000000000		2		1	200.00	200.00	2		2	2								
H1417	001	0	1	04	01	H1417_001_0	3	4	DME	01	000000000000000000000000111000000000		2		2			2		2	1			20	20				
H1417	001	0	1	04	01	H1417_001_0	3	3	Ambulance	01	000000000000000000000001000000000000		2		1	50.00	50.00	2		2	2								
H1417	001	0	1	04	01	H1417_001_0	3	2	Renal Dialysis	11	000000000000000000000010000100000000	000000100000000000000000	2		1	0.00	0.00	2		2	2								
H1417	001	0	1	04	01	H1417_001_0	3	1	Office Visits	11	011111111111111111100100000011111101	000000000001000100001010	2		1	30.00	30.00	2		2	2								
H1417	002	0	1	04	01	H1417_002_0	9	6	Eye Wear	01	000000000000000000000000000000000010		2		1	0.00	0.00	2		2	2								
H1417	002	0	1	04	01	H1417_002_0	9	1	Office Visits	11	011111111111111111100100000011111101	000000000001000100001010	2		1	30.00	30.00	2		2	2								
H1417	002	0	1	04	01	H1417_002_0	9	2	Renal Dialysis	11	000000000000000000000010000100000000	000000100000000000000000	2		1	0.00	0.00	2		2	2								
H1417	002	0	1	04	01	H1417_002_0	9	3	Ambulance	01	000000000000000000000001000000000000		2		1	50.00	50.00	2		2	2								
H1417	002	0	1	04	01	H1417_002_0	9	4	DME	01	000000000000000000000000111000000000		2		2			2		2	1			20	20				
H1417	002	0	1	04	01	H1417_002_0	9	5	ASC	01	000000000000000000011000000000000000		2		1	200.00	200.00	2		2	2								
H1417	003	0	1	04	01	H1417_003_0	3	6	Eye Wear	01	000000000000000000000000000000000010		2		1	0.00	0.00	2		2	2								
H1417	003	0	1	04	01	H1417_003_0	3	5	ASC	01	000000000000000000011000000000000000		2		1	200.00	200.00	2		2	2								
H1417	003	0	1	04	01	H1417_003_0	3	4	DME	01	000000000000000000000000111000000000		2		2			2		2	1			20	20				
H1417	003	0	1	04	01	H1417_003_0	3	3	Ambulance	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H1417	003	0	1	04	01	H1417_003_0	3	1	Office Visits	11	011111111111111111100100000011111101	000000000001000100001000	2		1	50.00	50.00	2		2	2								
H1417	003	0	1	04	01	H1417_003_0	3	2	Renal Dialysis	11	000000000000000000000010000100000000	000000100000000000000000	2		1	0.00	0.00	2		2	2								
H1417	004	0	1	04	01	H1417_004_0	9	5	ASC	01	000000000000000000011000000000000000		2		1	200.00	200.00	2		2	2								
H1417	004	0	1	04	01	H1417_004_0	9	4	DME	01	000000000000000000000000111000000000		2		2			2		2	1			20	20				
H1417	004	0	1	04	01	H1417_004_0	9	3	Ambulance	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H1417	004	0	1	04	01	H1417_004_0	9	2	Renal Dialysis	11	000000000000000000000010000100000000	000000100000000000000000	2		1	0.00	0.00	2		2	2								
H1417	004	0	1	04	01	H1417_004_0	9	1	Office Visits	11	011111111111111111100100000011111101	000000000001000100001000	2		1	50.00	50.00	2		2	2								
H1417	004	0	1	04	01	H1417_004_0	9	6	Eye Wear	01	000000000000000000000000000000000010		2		1	0.00	0.00	2		2	2								
H1417	801	0	1	04	01	H1417_801_0	1	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H1417	801	0	1	04	01	H1417_801_0	1	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H1417	801	0	1	04	01	H1417_801_0	1	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H1417	802	0	1	04	01	H1417_802_0	1	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H1417	802	0	1	04	01	H1417_802_0	1	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H1417	802	0	1	04	01	H1417_802_0	1	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H1418	002	0	1	04	01	H1418_002_0	5	5		01	000000000000000000000000000010000000		2		2			2		2	1			0	50				
H1418	002	0	1	04	01	H1418_002_0	5	3		01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H1418	002	0	1	04	01	H1418_002_0	5	4		11	000000000000000000000010000000000010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H1418	002	0	1	04	01	H1418_002_0	5	2		01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H1418	002	0	1	04	01	H1418_002_0	5	1		11	011111111111111111111100111001111101	000000000110000110110000	2		2			2		2	1			50	50				
H1418	007	0	1	04	01	H1418_007_0	4	7		01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H1418	007	0	1	04	01	H1418_007_0	4	6		10		000000000110000010110000	2		2			2		2	1			50	50				
H1418	007	0	1	04	01	H1418_007_0	4	5		11	000000000000000000000010000000000010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H1418	007	0	1	04	01	H1418_007_0	4	1		10		000000000000000000000010	2		1	35.00	35.00	2		2	2								
H1418	007	0	1	04	01	H1418_007_0	4	2		11	011111111111111111111100111001111101	000001000000000100000000	2		2			2		2	1			30	30				
H1418	007	0	1	04	01	H1418_007_0	4	4		01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H1418	007	0	1	04	01	H1418_007_0	4	3		01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H1418	008	0	1	04	01	H1418_008_0	5	1		11	011111111111111111111100111001101101	000000000000000100000000	2		2			2		2	1			30	30				
H1418	008	0	1	04	01	H1418_008_0	5	2		01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H1418	008	0	1	04	01	H1418_008_0	5	3		01	000000000000000000000000000100000000		2		2			2		2	1			0	20				
H1418	008	0	1	04	01	H1418_008_0	5	4		11	000000000000000000000010000000000010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H1418	008	0	1	04	01	H1418_008_0	5	6		01	000000000000000000000000000000010000		2		2			2		2	1			20	30				
H1418	008	0	1	04	01	H1418_008_0	5	5		10		000000000100000010110000	2		2			2		2	1			50	50				
H1418	008	0	1	04	01	H1418_008_0	5	7		01	000000000000000000000000000010000000		2		2			2		2	1			0	50				
H1418	009	0	1	04	01	H1418_009_0	3	6		01	000000000000000000000000000000010000		2		2			2		2	1			20	30				
H1418	009	0	1	04	01	H1418_009_0	3	7		01	000000000000000000000000000010000000		2		2			2		2	1			0	50				
H1418	009	0	1	04	01	H1418_009_0	3	1		11	011111111111111111111100111001101101	000000000000000100000000	2		2			2		2	1			30	30				
H1418	009	0	1	04	01	H1418_009_0	3	3		01	000000000000000000000000000100000000		2		2			2		2	1			0	20				
H1418	009	0	1	04	01	H1418_009_0	3	2		01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H1418	009	0	1	04	01	H1418_009_0	3	5		10		000000000110000010110000	2		2			2		2	1			50	50				
H1418	009	0	1	04	01	H1418_009_0	3	4		11	000000000000000000000010000000000010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H1509	001	0	1	04	01	H1509_001_0	7	2	Group 2	11	011100011101001000000000000000001101	000001000000000000001010	2		1	50.00	50.00	2		2	2								
H1509	001	0	1	04	01	H1509_001_0	7	3	Group 3	11	000000000000000011011000011001110010	000000000001000100000000	2		2			2		2	1			30	30				
H1509	001	0	1	04	01	H1509_001_0	7	4	Group 4	01	000000000000000100000000000000000000		2		1	14.00	14.00	2		2	1			30	30				
H1509	001	0	1	04	01	H1509_001_0	7	5	Group 5	01	000000000000000000100000000000000000		2		1	21.00	21.00	2		2	2								
H1509	001	0	1	04	01	H1509_001_0	7	6	Group 6	01	000010000000000000000000000000000000		2		1	75.00	75.00	2		2	2								
H1509	001	0	1	04	01	H1509_001_0	7	7	Group 7	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H1509	001	0	1	04	01	H1509_001_0	7	8	Group 8	01	000000000010010000000100000000000000		2		1	35.00	45.00	2		2	2								
H1509	001	0	1	04	01	H1509_001_0	7	9	Group 9	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H1509	001	0	1	04	01	H1509_001_0	7	1	Group 1	01	000000100000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H1509	001	0	1	04	01	H1509_001_0	7	10	Group 10	11	000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2	2								
H1509	001	0	1	04	01	H1509_001_0	7	11	Group 11	01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H1509	001	0	1	04	01	H1509_001_0	7	12	Group 12	01	000001000000000000000000100000000000		2		2			2		2	1			50	50				
H1509	001	0	1	04	01	H1509_001_0	7	13	Group 13	01	000000000000100000000000000000000000		2		1	30.00	50.00	2		2	2								
H1509	001	0	1	04	01	H1509_001_0	7	14	Group 14	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H1509	004	0	1	04	01	H1509_004_0	6	5	Group 5	10		000000010000000000100000	2		2			2		2	1			75	75				
H1509	004	0	1	04	01	H1509_004_0	6	1	Group 1	11	011111111111111011111111111001111101	000001100000000000001000	2		2			2		2	1			30	30				
H1509	004	0	1	04	01	H1509_004_0	6	2	Group 2	01	000000000000000100000000000010000000		2		2			2		2	1			0	30				
H1509	004	0	1	04	01	H1509_004_0	6	3	Group 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H1509	004	0	1	04	01	H1509_004_0	6	4	Group 4	11	000000000000000000000000000000000010	000000000000000010000100	2		1	0.00	0.00	2		2	2								
H1509	006	0	1	04	01	H1509_006_0	6	5	Group 5	01	000000000000000100000000000010000000		2		2			2		2	1			0	30				
H1509	006	0	1	04	01	H1509_006_0	6	1	Group 1	11	011111111111111011111111111001111101	000001100000000000001000	2		2			2		2	1			30	30				
H1509	006	0	1	04	01	H1509_006_0	6	4	Group 4	10		000000010000000000000000	2		2			2		2	1			75	75				
H1509	006	0	1	04	01	H1509_006_0	6	2	Group 2	11	000000000000000000000000000000000010	000000000100000000110100	2		1	0.00	0.00	2		2	2								
H1509	006	0	1	04	01	H1509_006_0	6	3	Group 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H1509	007	0	1	04	01	H1509_007_0	7	9	Group 9	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H1509	007	0	1	04	01	H1509_007_0	7	8	Group 8	01	000000000010010000000100000000000000		2		1	35.00	45.00	2		2	2								
H1509	007	0	1	04	01	H1509_007_0	7	7	Gorup 7	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H1509	007	0	1	04	01	H1509_007_0	7	6	Group 6	01	000010000000000000000000000000000000		2		1	75.00	75.00	2		2	2								
H1509	007	0	1	04	01	H1509_007_0	7	5	Group 5	01	000000000000000000100000000000000000		2		1	21.00	21.00	2		2	2								
H1509	007	0	1	04	01	H1509_007_0	7	4	Group 4	01	000000000000000100000000000000000000		2		1	14.00	14.00	2		2	1			30	30				
H1509	007	0	1	04	01	H1509_007_0	7	3	Group 3	11	000000000000000011011000011001110010	000000000001000100000000	2		2			2		2	1			30	30				
H1509	007	0	1	04	01	H1509_007_0	7	2	Group 2	11	011100011101001000000000000000001101	000001000000000000001010	2		1	45.00	45.00	2		2	2								
H1509	007	0	1	04	01	H1509_007_0	7	14	Group 14	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H1509	007	0	1	04	01	H1509_007_0	7	13	Group 13	01	000000000000100000000000000000000000		2		1	25.00	45.00	2		2	2								
H1509	007	0	1	04	01	H1509_007_0	7	12	Group 12	01	000001000000000000000000100000000000		2		2			2		2	1			50	50				
H1509	007	0	1	04	01	H1509_007_0	7	11	Group 11	01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H1509	007	0	1	04	01	H1509_007_0	7	10	Group 10	11	000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2	2								
H1509	007	0	1	04	01	H1509_007_0	7	1	Group 1	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H1509	009	0	1	04	01	H1509_009_0	7	1	Group 1	01	000000100000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H1509	009	0	1	04	01	H1509_009_0	7	13	Group 13	01	000000000000100000000000000000000000		2		1	20.00	50.00	2		2	2								
H1509	009	0	1	04	01	H1509_009_0	7	12	Group 12	01	000001000000000000000000100000000000		2		2			2		2	1			50	50				
H1509	009	0	1	04	01	H1509_009_0	7	11	Group 11	01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H1509	009	0	1	04	01	H1509_009_0	7	14	Group 14	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H1509	009	0	1	04	01	H1509_009_0	7	2	Group 2	11	011100011101001000000000000000001101	000001000000000000001010	2		1	50.00	50.00	2		2	2								
H1509	009	0	1	04	01	H1509_009_0	7	10	Group 10	11	000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2	2								
H1509	009	0	1	04	01	H1509_009_0	7	4	Group 4	01	000000000000000100000000000000000000		2		1	16.00	16.00	2		2	1			30	30				
H1509	009	0	1	04	01	H1509_009_0	7	5	Group 5	01	000000000000000000100000000000000000		2		1	21.00	21.00	2		2	2								
H1509	009	0	1	04	01	H1509_009_0	7	6	Group 6	01	000010000000000000000000000000000000		2		1	75.00	75.00	2		2	2								
H1509	009	0	1	04	01	H1509_009_0	7	7	Group 7	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H1509	009	0	1	04	01	H1509_009_0	7	8	Group 8	01	000000000010010000000100000000000000		2		1	35.00	45.00	2		2	2								
H1509	009	0	1	04	01	H1509_009_0	7	9	Group 9	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H1509	009	0	1	04	01	H1509_009_0	7	3	Group 3	11	000000000000000011011000011001110010	000000000001000100000000	2		2			2		2	1			30	30				
H1509	010	0	1	04	01	H1509_010_0	7	13	Group 13	01	000000000000100000000000000000000000		2		1	25.00	45.00	2		2	2								
H1509	010	0	1	04	01	H1509_010_0	7	10	Group 10	11	000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2	2								
H1509	010	0	1	04	01	H1509_010_0	7	11	Group 11	01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H1509	010	0	1	04	01	H1509_010_0	7	12	Group 12	01	000001000000000000000000100000000000		2		2			2		2	1			50	50				
H1509	010	0	1	04	01	H1509_010_0	7	1	Group 1	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H1509	010	0	1	04	01	H1509_010_0	7	14	Group 14	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H1509	010	0	1	04	01	H1509_010_0	7	2	Group 2	11	011100011101001000000000000000001101	000001000000000000001010	2		1	45.00	45.00	2		2	2								
H1509	010	0	1	04	01	H1509_010_0	7	3	Group 3	11	000000000000000011011000011001110010	000000000001000100000000	2		2			2		2	1			30	30				
H1509	010	0	1	04	01	H1509_010_0	7	4	Group 4	01	000000000000000100000000000000000000		2		1	14.00	14.00	2		2	1			30	30				
H1509	010	0	1	04	01	H1509_010_0	7	5	Group 5	01	000000000000000000100000000000000000		2		1	21.00	21.00	2		2	2								
H1509	010	0	1	04	01	H1509_010_0	7	9	Group 9	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H1509	010	0	1	04	01	H1509_010_0	7	8	Group 8	01	000000000010010000000100000000000000		2		1	35.00	45.00	2		2	2								
H1509	010	0	1	04	01	H1509_010_0	7	7	Gorup 7	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H1509	010	0	1	04	01	H1509_010_0	7	6	Group 6	01	000010000000000000000000000000000000		2		1	75.00	75.00	2		2	2								
H1509	801	0	1	04	01	H1509_801_0	1	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H1509	801	0	1	04	01	H1509_801_0	1	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H1509	801	0	1	04	01	H1509_801_0	1	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H1509	803	0	1	04	01	H1509_803_0	1	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H1509	803	0	1	04	01	H1509_803_0	1	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H1509	803	0	1	04	01	H1509_803_0	1	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H1509	804	0	1	04	01	H1509_804_0	1	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H1509	804	0	1	04	01	H1509_804_0	1	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H1509	804	0	1	04	01	H1509_804_0	1	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H1509	806	0	2	04	01	H1509_806_0	1	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H1509	806	0	2	04	01	H1509_806_0	1	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H1509	806	0	2	04	01	H1509_806_0	1	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H1509	807	0	2	04	01	H1509_807_0	1	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H1509	807	0	2	04	01	H1509_807_0	1	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H1509	807	0	2	04	01	H1509_807_0	1	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H1509	808	0	2	04	01	H1509_808_0	1	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H1509	808	0	2	04	01	H1509_808_0	1	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H1509	808	0	2	04	01	H1509_808_0	1	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H1509	809	0	1	04	01	H1509_809_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H1509	809	0	1	04	01	H1509_809_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H1509	809	0	1	04	01	H1509_809_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H1509	810	0	1	04	01	H1509_810_0	1	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H1509	810	0	1	04	01	H1509_810_0	1	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H1509	810	0	1	04	01	H1509_810_0	1	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H1509	811	0	1	04	01	H1509_811_0	1	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H1509	811	0	1	04	01	H1509_811_0	1	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H1509	811	0	1	04	01	H1509_811_0	1	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H1509	812	0	1	04	01	H1509_812_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H1509	812	0	1	04	01	H1509_812_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H1509	812	0	1	04	01	H1509_812_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H1509	813	0	1	04	01	H1509_813_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H1509	813	0	1	04	01	H1509_813_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H1509	813	0	1	04	01	H1509_813_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H1509	814	0	1	04	01	H1509_814_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H1509	814	0	1	04	01	H1509_814_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H1509	814	0	1	04	01	H1509_814_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H1509	815	0	1	04	01	H1509_815_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H1509	815	0	1	04	01	H1509_815_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H1509	815	0	1	04	01	H1509_815_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H1509	816	0	1	04	01	H1509_816_0	1	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H1509	816	0	1	04	01	H1509_816_0	1	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H1509	816	0	1	04	01	H1509_816_0	1	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H1509	817	0	1	04	01	H1509_817_0	1	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H1509	817	0	1	04	01	H1509_817_0	1	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H1509	817	0	1	04	01	H1509_817_0	1	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H1509	819	0	1	04	01	H1509_819_0	1	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H1509	819	0	1	04	01	H1509_819_0	1	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H1509	819	0	1	04	01	H1509_819_0	1	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H1510	001	0	1	04	01	H1510_001_0	4	6		01	000000000000000000000000000000010000		2		2			2		2	1			20	30				
H1510	001	0	1	04	01	H1510_001_0	4	5		10		000000000000000010110000	2		2			2		2	1			50	50				
H1510	001	0	1	04	01	H1510_001_0	4	4		11	000000000000000000000010000000000010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H1510	001	0	1	04	01	H1510_001_0	4	3		01	000000000000000000000000000100000000		2		2			2		2	1			0	20				
H1510	001	0	1	04	01	H1510_001_0	4	2		01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H1510	001	0	1	04	01	H1510_001_0	4	1		11	011111111111111111111100111001101101	000000000000000100000000	2		2			2		2	1			30	30				
H1510	001	0	1	04	01	H1510_001_0	4	7		01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H1510	004	0	1	04	01	H1510_004_0	4	2		01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H1510	004	0	1	04	01	H1510_004_0	4	3		01	000000000000000000000000000100000000		2		2			2		2	1			0	20				
H1510	004	0	1	04	01	H1510_004_0	4	4		11	000000000000000000000010000000000010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H1510	004	0	1	04	01	H1510_004_0	4	5		10		000000000110000010110000	2		2			2		2	1			50	50				
H1510	004	0	1	04	01	H1510_004_0	4	6		01	000000000000000000000000000000010000		2		2			2		2	1			20	30				
H1510	004	0	1	04	01	H1510_004_0	4	7		01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H1510	004	0	1	04	01	H1510_004_0	4	1		11	011111111111111111111100111001101101	000000000000000100000000	2		2			2		2	1			30	30				
H1510	005	0	1	04	01	H1510_005_0	5	7		01	000000000000000000000000000000010000		2		2			2		2	1			20	30				
H1510	005	0	1	04	01	H1510_005_0	5	8		01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H1510	005	0	1	04	01	H1510_005_0	5	6		10		000000000000000010110000	2		2			2		2	1			50	50				
H1510	005	0	1	04	01	H1510_005_0	5	5		11	000000000000000000000010000000000010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H1510	005	0	1	04	01	H1510_005_0	5	4		01	000000000000000000000000000100000000		2		2			2		2	1			0	20				
H1510	005	0	1	04	01	H1510_005_0	5	3		01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H1510	005	0	1	04	01	H1510_005_0	5	2		11	011111111111111111111100111001101101	000000000000000100000000	2		2			2		2	1			30	30				
H1510	005	0	1	04	01	H1510_005_0	5	1		10		000000000000000000000011	2		2			2		2	1			25	25				
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H1510	008	0	1	04	01	H1510_008_0	5	2		01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
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H1517	005	0	1	04	01	H1517_005_0	11	9	$20-$55 / 25%	01	000000000000000000010000000000000000		2		1	20.00	55.00	2		2	1			25	25				
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H2001	001	0	1	04	01	H2001_001_0	7	3	Group 3	11	000000000000000011011000011001110010	000000000001000100000000	2		2			2		2	1			30	30				
H2001	001	0	1	04	01	H2001_001_0	7	9	Group 9	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H2001	001	0	1	04	01	H2001_001_0	7	14	Group 14	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H2001	001	0	1	04	01	H2001_001_0	7	13	Group 13	01	000000000000100000000000000000000000		2		1	25.00	45.00	2		2	2								
H2001	001	0	1	04	01	H2001_001_0	7	12	Group 12	01	000001000000000000000000100000000000		2		2			2		2	1			50	50				
H2001	001	0	1	04	01	H2001_001_0	7	11	Group 11	01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H2001	001	0	1	04	01	H2001_001_0	7	10	Group 10	11	000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2	2								
H2001	001	0	1	04	01	H2001_001_0	7	1	Group 1	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H2001	001	0	1	04	01	H2001_001_0	7	2	Group 2	11	011100011101001000000000000000001101	000001000000000000001010	2		1	45.00	45.00	2		2	2								
H2029	001	0	1	04	01	H2029_001_0	9	5		10		000000000110000010110000	2		2			2		2	1			50	50				
H2029	001	0	1	04	01	H2029_001_0	9	4		11	000000000000000000000010000000000000	000000100000000000001100	2		1	0.00	0.00	2		2	2								
H2029	001	0	1	04	01	H2029_001_0	9	3		01	000000000000000000000000000100000000		2		2			2		2	1			0	20				
H2029	001	0	1	04	01	H2029_001_0	9	2		01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H2029	001	0	1	04	01	H2029_001_0	9	1		11	011111111111111111111100111011111111	000000000000000100000000	2		2			2		2	1			30	30				
H2029	002	0	1	04	01	H2029_002_0	9	2		11	000000000000000000000011000000000010	000000100000000000001100	2		1	0.00	0.00	2		2	2								
H2029	002	0	1	04	01	H2029_002_0	9	5		01	000000000000000000000000000010000000		2		1	0.00	0.00	2		2	1			30	30				
H2029	002	0	1	04	01	H2029_002_0	9	1		11	011111111111111111111100111001111101	000000000000000100000000	2		2			2		2	1			30	30				
H2029	002	0	1	04	01	H2029_002_0	9	4		10		000000000110000010110000	2		2			2		2	1			50	50				
H2029	002	0	1	04	01	H2029_002_0	9	3		01	000000000000000000000000000100000000		2		2			2		2	1			0	20				
H2029	801	0	1	04	01	H2029_801_0	7	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H2029	801	0	1	04	01	H2029_801_0	7	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H2029	801	0	1	04	01	H2029_801_0	7	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H2029	802	0	1	04	01	H2029_802_0	5	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H2029	802	0	1	04	01	H2029_802_0	5	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H2029	802	0	1	04	01	H2029_802_0	5	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H2029	803	0	1	04	01	H2029_803_0	5	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H2029	803	0	1	04	01	H2029_803_0	5	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H2029	803	0	1	04	01	H2029_803_0	5	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H2029	805	0	2	04	01	H2029_805_0	5	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H2029	805	0	2	04	01	H2029_805_0	5	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H2029	805	0	2	04	01	H2029_805_0	5	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H2029	806	0	2	04	01	H2029_806_0	5	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H2029	806	0	2	04	01	H2029_806_0	5	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H2029	806	0	2	04	01	H2029_806_0	5	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H2029	807	0	2	04	01	H2029_807_0	5	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H2029	807	0	2	04	01	H2029_807_0	5	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H2029	807	0	2	04	01	H2029_807_0	5	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H2029	808	0	1	04	01	H2029_808_0	5	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H2029	808	0	1	04	01	H2029_808_0	5	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H2029	808	0	1	04	01	H2029_808_0	5	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H2038	001	0	1	09	04	H2038_001_0	5	2		11	000001000000000000000010000011100000	000000100000000100001000	2		1	0.00	0.00	2		2	2								
H2038	001	0	1	09	04	H2038_001_0	5	1		01	011110111111111011111101111100011011		2		2			2		2	1			20	20				
H2038	001	0	1	09	04	H2038_001_0	5	4		10		000000000110000010000000	2		2			2		2	1			50	50				
H2038	001	0	1	09	04	H2038_001_0	5	5		01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H2038	001	0	1	09	04	H2038_001_0	5	3		01	000000000000000100000000000000000000		2		1	0.00	0.00	2		2	1			0	0				
H2038	002	0	1	09	04	H2038_002_0	6	1		01	000010000000000000001001111100010000		2		2			2		2	1			20	20				
H2038	002	0	1	09	04	H2038_002_0	6	9		01	000000000000000000010000000000000000		2		2			2		2	1			20	25				
H2038	002	0	1	09	04	H2038_002_0	6	8		01	000000000000000001000000000000000000		2		1	40.00	40.00	2		2	1			20	20				
H2038	002	0	1	09	04	H2038_002_0	6	6		01	000000000000000100000000000000000000		2		1	0.00	40.00	2		2	1			20	25				
H2038	002	0	1	09	04	H2038_002_0	6	10		01	000000000000000000000100000000000000		2		2			2		2	1			25	25				
H2038	002	0	1	09	04	H2038_002_0	6	11		10		000000000110000010000000	2		2			2		2	1			50	50				
H2038	002	0	1	09	04	H2038_002_0	6	12		01	000000000000000000000000000000000100		2		1	0.00	40.00	2		2	2								
H2038	002	0	1	09	04	H2038_002_0	6	2		11	000001000000000000000010000011100000	000000100000000100001000	2		1	0.00	0.00	2		2	2								
H2038	002	0	1	09	04	H2038_002_0	6	3		01	000000110000000000000000000000000000		2		1	15.00	15.00	2		2	2								
H2038	002	0	1	09	04	H2038_002_0	6	4		01	011100001000001000000000000000000000		2		1	40.00	40.00	2		2	1			20	25				
H2038	002	0	1	09	04	H2038_002_0	6	5		01	000000000111110000000000000000001001		2		1	40.00	40.00	2		2	2								
H2038	002	0	1	09	04	H2038_002_0	6	7		01	000000000000000010100000000000000000		2		1	15.00	40.00	2		2	1			20	25				
H2038	002	0	1	09	04	H2038_002_0	6	13		01	000000000000000000000000000000000010		2		1	25.00	25.00	2		2	2								
H2111	001	0	1	04	01	H2111_001_0	6	1	Group 1	11	011111111111111011111111111001101101	000001100000000000001010	2		2			2		2	1			30	30				
H2111	001	0	1	04	01	H2111_001_0	6	2	Group 2	11	000000000000000000000000000000000010	000000000100000000110101	2		1	0.00	0.00	2		2	2								
H2111	001	0	1	04	01	H2111_001_0	6	3	Group 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H2111	001	0	1	04	01	H2111_001_0	6	4	Group 4	10		000000010000000000000000	2		2			2		2	1			75	75				
H2111	001	0	1	04	01	H2111_001_0	6	5	Group 5	01	000000000000000100000000000010000000		2		2			2		2	1			0	30				
H2111	001	0	1	04	01	H2111_001_0	6	6	Group 6	01	000000000000000000000000000000010000		2		2			2		2	1			29	29				
H2111	008	0	1	04	01	H2111_008_0	7	1	Group 1	11	011111111111111011111111111001111101	000001100000000000001000	2		2			2		2	1			30	30				
H2111	008	0	1	04	01	H2111_008_0	7	2	Group 2	01	000000000000000100000000000010000000		2		2			2		2	1			0	30				
H2111	008	0	1	04	01	H2111_008_0	7	3	Group 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H2111	008	0	1	04	01	H2111_008_0	7	4	Group 4	11	000000000000000000000000000000000010	000000000100000010000100	2		1	0.00	0.00	2		2	2								
H2111	008	0	1	04	01	H2111_008_0	7	5	Group 5	10		000000010000000000100000	2		2			2		2	1			75	75				
H2228	001	0	1	04	01	H2228_001_0	6	3	Group 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H2228	001	0	1	04	01	H2228_001_0	6	4	Group 4	10		000000010000000000000000	2		2			2		2	1			75	75				
H2228	001	0	1	04	01	H2228_001_0	6	2	Group 2	11	000000000000000000000000000000000010	000000000000000000000100	2		1	0.00	0.00	2		2	2								
H2228	001	0	1	04	01	H2228_001_0	6	1	Group 1	11	011111111111111011111111111001111101	000001100000000000001000	2		2			2		2	1			30	30				
H2228	001	0	1	04	01	H2228_001_0	6	5	Group 5	01	000000000000000100000000000010000000		2		2			2		2	1			0	30				
H2228	002	0	1	04	01	H2228_002_0	6	4	Group 4	10		000000010000000000000000	2		2			2		2	1			75	75				
H2228	002	0	1	04	01	H2228_002_0	6	5	Group 5	01	000000000000000100000000000010000000		2		2			2		2	1			0	30				
H2228	002	0	1	04	01	H2228_002_0	6	3	Group 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H2228	002	0	1	04	01	H2228_002_0	6	1	Group 1	11	011111111111111011111111111001111101	000001100000000000001000	2		2			2		2	1			30	30				
H2228	002	0	1	04	01	H2228_002_0	6	2	Group 2	11	000000000000000000000000000000000010	000000000000000000000100	2		1	0.00	0.00	2		2	2								
H2230	002	0	1	04	01	H2230_002_0	12	1		11	011111011010011111111110111001100000	000000100000000000000000	2		2			2		2	1			20	20				
H2230	002	0	1	04	01	H2230_002_0	12	5		01	000000000000000000000000000010001000		2		1	0.00	40.00	2		2	1			0	20				
H2230	002	0	1	04	01	H2230_002_0	12	4		11	000000000000000000000000000000010010	000000000001000010000101	2		1	0.00	0.00	2		2	2								
H2230	002	0	1	04	01	H2230_002_0	12	3		01	000000000000000000000001000000000000		2		1	0.00	100.00	2		2	2								
H2230	002	0	1	04	01	H2230_002_0	12	2		11	000000100101100000000000000000000101	000000000000000000101010	2		1	40.00	40.00	2		2	2								
H2230	002	0	1	04	01	H2230_002_0	12	6		01	000000000000000000000000000100000000		2		2			2		2	1			0	20				
H2230	016	0	1	04	01	H2230_016_0	11	9		01	000000000000000100011000000000000000		2		1	0.00	200.00	2		2	2								
H2230	016	0	1	04	01	H2230_016_0	11	8		01	000000100000000100000000000000000000		2		1	0.00	20.00	2		2	2								
H2230	016	0	1	04	01	H2230_016_0	11	7		01	000000000000000000000000110000000000		2		2			2		2	1			0	20				
H2230	016	0	1	04	01	H2230_016_0	11	6		01	000000000000000000000001000000000000		2		1	0.00	100.00	2		2	2								
H2230	016	0	1	04	01	H2230_016_0	11	5		11	000000000010010000000100000000001000	000000000000000000001000	2		1	40.00	40.00	2		2	2								
H2230	016	0	1	04	01	H2230_016_0	11	4		01	000000000100100000000000000000000100		2		1	0.00	40.00	2		2	2								
H2230	016	0	1	04	01	H2230_016_0	11	3		11	000000000001000000000000000000000001	000000000000000000000010	2		1	20.00	40.00	2		2	2								
H2230	016	0	1	04	01	H2230_016_0	11	2		11	000011000000000001000010001111010010	000000100001000010000100	2		1	0.00	0.00	2		2	2								
H2230	016	0	1	04	01	H2230_016_0	11	11		01	000000000000000000000000000000100000		2		1	0.00	40.00	2		1	2	2					1	20.00	40.00
H2230	016	0	1	04	01	H2230_016_0	11	1		01	011100011000001000000000000000000000		2		1	20.00	20.00	2		2	2								
H2230	016	0	1	04	01	H2230_016_0	11	10		01	000000000000000010100000000000000000		2		1	0.00	150.00	2		2	2								
H2230	801	0	1	04	01	H2230_801_0	7	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H2230	801	0	1	04	01	H2230_801_0	7	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H2230	801	0	1	04	01	H2230_801_0	7	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H2230	809	0	1	04	01	H2230_809_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H2230	809	0	1	04	01	H2230_809_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H2230	809	0	1	04	01	H2230_809_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H2322	004	0	1	04	01	H2322_004_0	8	3		10		000000000000000010000000	1	25.00	2			2		2	2								
H2322	004	0	1	04	01	H2322_004_0	8	2		01	000010000010010000000100110000000010		2		2			2		2	1			50	50				
H2322	004	0	1	04	01	H2322_004_0	8	1		11	011101111101101111111011001111111101	000000100000000010001010	2		2			2		2	1			20	20				
H2322	008	0	1	04	01	H2322_008_0	9	2		01	000010000010010000000100110000000010		2		2			2		2	1			50	50				
H2322	008	0	1	04	01	H2322_008_0	9	3		10		000000000000000010000000	1	25.00	2			2		2	2								
H2322	008	0	1	04	01	H2322_008_0	9	1		11	011101111101101111111011001111111101	000000100000000010001010	2		2			2		2	1			25	25				
H2322	801	0	1	04	01	H2322_801_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H2322	801	0	1	04	01	H2322_801_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H2322	801	0	1	04	01	H2322_801_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H2322	803	0	1	04	01	H2322_803_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H2322	803	0	1	04	01	H2322_803_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H2322	803	0	1	04	01	H2322_803_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H2406	001	0	1	04	01	H2406_001_0	6	4	Group 4	10		000000010000000000000000	2		2			2		2	1			75	75				
H2406	001	0	1	04	01	H2406_001_0	6	3	Group 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H2406	001	0	1	04	01	H2406_001_0	6	5	Group 5	01	000000000000000100000000000010000000		2		2			2		2	1			0	30				
H2406	001	0	1	04	01	H2406_001_0	6	1	Group 1	11	011111111111111011111111111001111101	000001100000000000001000	2		2			2		2	1			30	30				
H2406	001	0	1	04	01	H2406_001_0	6	2	Group 2	11	000000000000000000000000000000000010	000000000100000000110100	2		1	0.00	0.00	2		2	2								
H2411	801	0	1	04	01	H2411_801_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H2411	801	0	1	04	01	H2411_801_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H2411	801	0	1	04	01	H2411_801_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H2411	803	0	1	04	01	H2411_803_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H2411	803	0	1	04	01	H2411_803_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H2411	803	0	1	04	01	H2411_803_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H2542	001	0	1	04	01	H2542_001_0	6	9		01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H2542	001	0	1	04	01	H2542_001_0	6	3		01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H2542	001	0	1	04	01	H2542_001_0	6	8		01	000000000000000000000000000000010000		2		2			2		2	1			20	30				
H2542	001	0	1	04	01	H2542_001_0	6	7		10		000000000110000010110000	2		2			2		2	1			50	50				
H2542	001	0	1	04	01	H2542_001_0	6	2		11	011111111111111111111100000001101101	000000000000000100000000	2		2			2		2	1			30	30				
H2542	001	0	1	04	01	H2542_001_0	6	6		11	000000000000000000000010000000000010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H2542	001	0	1	04	01	H2542_001_0	6	5		01	000000000000000000000000000100000000		2		2			2		2	1			0	20				
H2542	001	0	1	04	01	H2542_001_0	6	1		10		000000000000000000000011	2		2			2		2	1			25	25				
H2542	001	0	1	04	01	H2542_001_0	6	4		01	000000000000000000000000111000000000		2		2			2		2	1			40	40				
H2542	002	0	1	04	01	H2542_002_0	5	1		10		000000000000000000000011	2		2			2		2	1			25	25				
H2542	002	0	1	04	01	H2542_002_0	5	2		11	011111111111111111111100000001101101	000000000000000100000000	2		2			2		2	1			30	30				
H2542	002	0	1	04	01	H2542_002_0	5	3		01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
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H3335	002	0	1	04	01	H3335_002_0	7	2	50% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			50	50				
H3335	002	0	1	04	01	H3335_002_0	7	3	$150 Copayment	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H3335	002	0	1	04	01	H3335_002_0	7	4	$0 Copayment	01	000000000000000000000000000100000000		2		1	0.00	0.00	2		2	2								
H3335	002	0	1	04	01	H3335_002_0	7	5	Supplemental Education/Wellness Programs	10		000000000000000010000000	2		1	0.00	0.00	2		2	2								
H3335	002	0	1	04	01	H3335_002_0	7	1	30% Coinsurance	11	011101111101101111111010111011111111	000000100000000100001000	2		2			2		2	1			30	30				
H3335	005	0	1	04	01	H3335_005_0	6	6	Supplemental Education/Wellness Programs	10		000000000000000010000000	2		1	0.00	0.00	2		2	2								
H3335	005	0	1	04	01	H3335_005_0	6	8	$45 Copay - Specialist Services	11	011100001101101000000000000000001111	000000000000000000001000	2		1	45.00	45.00	2		2	2								
H3335	005	0	1	04	01	H3335_005_0	6	5	Preventive Services	01	000000000000000000000000000010000000		2		1	0.00	20.00	2		2	1			30	30				
H3335	005	0	1	04	01	H3335_005_0	6	4	$0 Copayment	11	000000000000000000000000000100000000	000000000000000000100000	2		1	0.00	0.00	2		2	2								
H3335	005	0	1	04	01	H3335_005_0	6	3	$100 Copayment	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H3335	005	0	1	04	01	H3335_005_0	6	2	50% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			50	50				
H3335	005	0	1	04	01	H3335_005_0	6	1	30% Coinsurance	11	000001000000000111011010111001110000	000000100000000000000000	2		2			2		2	1			30	30				
H3335	005	0	1	04	01	H3335_005_0	6	7	$20 Copay	11	000000110000000000100000000000000000	000000000000000100000000	2		1	20.00	20.00	2		2	2								
H3335	006	0	1	04	01	H3335_006_0	6	3	$100 Copayment	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H3335	006	0	1	04	01	H3335_006_0	6	9	$20 Copay	01	000000000000000000100000000000000000		2		1	20.00	20.00	2		2	2								
H3335	006	0	1	04	01	H3335_006_0	6	8	$40 Copayment - Specialist Services	11	011100001101101000000000000000001111	000000000000000000001000	2		1	40.00	40.00	2		2	2								
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H3335	006	0	1	04	01	H3335_006_0	6	6	Supplemental Education/Wellness Programs	10		000000000000000010000000	2		1	0.00	0.00	2		2	2								
H3335	006	0	1	04	01	H3335_006_0	6	5	Preventive Services	01	000000000000000000000000000010000000		2		1	0.00	20.00	2		2	1			30	30				
H3335	006	0	1	04	01	H3335_006_0	6	4	$0 Copayment	11	000000000000000000000000000100000000	000000000000000000100000	2		1	0.00	0.00	2		2	2								
H3335	006	0	1	04	01	H3335_006_0	6	2	50% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			50	50				
H3335	006	0	1	04	01	H3335_006_0	6	1	30% Coinsurance	11	000001000000000111011010111001110000	000000100000000000000000	2		2			2		2	1			30	30				
H3335	008	0	1	04	01	H3335_008_0	6	7	$20 Copay	11	000000110000000000100000000000000000	000000000000000100000000	2		1	20.00	20.00	2		2	2								
H3335	008	0	1	04	01	H3335_008_0	6	6	Supplemental Education/Wellness Programs	10		000000000000000010000000	2		1	0.00	0.00	2		2	2								
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H3335	008	0	1	04	01	H3335_008_0	6	4	$0 Copayment	11	000000000000000000000000000100000000	000000000000000000100000	2		1	0.00	0.00	2		2	2								
H3335	008	0	1	04	01	H3335_008_0	6	3	$100 Copayment	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H3335	008	0	1	04	01	H3335_008_0	6	2	50% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			50	50				
H3335	008	0	1	04	01	H3335_008_0	6	1	30% Coinsurance	11	000001000000000111011010111001110000	000000100000000000000000	2		2			2		2	1			30	30				
H3335	008	0	1	04	01	H3335_008_0	6	8	$45 Copay - Specialist Services	11	011100001101101000000000000000001111	000000000000000000001000	2		1	45.00	45.00	2		2	2								
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H3335	009	0	1	04	01	H3335_009_0	6	7	$20 Copay	11	000000110000000000000000000000000000	000000000000000100000000	2		1	20.00	20.00	2		2	2								
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H3335	009	0	1	04	01	H3335_009_0	6	5	Preventive Services	01	000000000000000000000000000010000000		2		1	0.00	20.00	2		2	1			30	30				
H3335	009	0	1	04	01	H3335_009_0	6	4	$0 Copayment	11	000000000000000000000000000100000000	000000000000000000100000	2		1	0.00	0.00	2		2	2								
H3335	009	0	1	04	01	H3335_009_0	6	3	$100 Copayment	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H3335	009	0	1	04	01	H3335_009_0	6	2	50% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			50	50				
H3335	009	0	1	04	01	H3335_009_0	6	9	$20 Copay	01	000000000000000000100000000000000000		2		1	20.00	20.00	2		2	2								
H3335	009	0	1	04	01	H3335_009_0	6	1	30% Coinsurance	11	000001000000000111011010111001110000	000000100000000000000000	2		2			2		2	1			30	30				
H3335	014	0	1	04	01	H3335_014_0	6	1	30% Coinsurance	11	000001000000000111011010111001110000	000000100000000000000000	2		2			2		2	1			30	30				
H3335	014	0	1	04	01	H3335_014_0	6	2	50% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			50	50				
H3335	014	0	1	04	01	H3335_014_0	6	3	$100 Copayment	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
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H3335	014	0	1	04	01	H3335_014_0	6	5	Preventive Services	01	000000000000000000000000000010000000		2		1	0.00	20.00	2		2	1			30	30				
H3335	014	0	1	04	01	H3335_014_0	6	8	$45 Copay - Specialist Services	11	011100001101101000000000000000001111	000000000000000000001000	2		1	45.00	45.00	2		2	2								
H3335	014	0	1	04	01	H3335_014_0	6	7	$20 Copay	11	000000110000000000100000000000000000	000000000000000100000000	2		1	20.00	20.00	2		2	2								
H3335	014	0	1	04	01	H3335_014_0	6	6	Supplemental Education/Wellness Programs	10		000000000000000010000000	2		1	0.00	0.00	2		2	2								
H3335	015	0	1	04	01	H3335_015_0	6	9	$20 Copay	01	000000000000000000100000000000000000		2		1	20.00	20.00	2		2	2								
H3335	015	0	1	04	01	H3335_015_0	6	1	30% Coinsurance	11	000001000000000111011010111001110000	000000100000000000000000	2		2			2		2	1			30	30				
H3335	015	0	1	04	01	H3335_015_0	6	2	50% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			50	50				
H3335	015	0	1	04	01	H3335_015_0	6	3	$100 Copayment	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H3335	015	0	1	04	01	H3335_015_0	6	4	$0 Copayment	11	000000000000000000000000000100000000	000000000000000000100000	2		1	0.00	0.00	2		2	2								
H3335	015	0	1	04	01	H3335_015_0	6	5	Preventive Services	01	000000000000000000000000000010000000		2		1	0.00	20.00	2		2	1			30	30				
H3335	015	0	1	04	01	H3335_015_0	6	6	Supplemental Education/Wellness Programs	10		000000000000000010000000	2		1	0.00	0.00	2		2	2								
H3335	015	0	1	04	01	H3335_015_0	6	7	$20 Copay	11	000000110000000000000000000000000000	000000000000000100000000	2		1	20.00	20.00	2		2	2								
H3335	015	0	1	04	01	H3335_015_0	6	8	$40 Copayment - Specialist Services	11	011100001101101000000000000000001111	000000000000000000001000	2		1	40.00	40.00	2		2	2								
H3335	018	0	1	04	01	H3335_018_0	6	1	30% Coinsurance	11	011101111101101111111010111001111111	000000100000000100001000	2		2			2		2	1			30	30				
H3335	018	0	1	04	01	H3335_018_0	6	2	50% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			50	50				
H3335	018	0	1	04	01	H3335_018_0	6	6	Supplemental Education/Wellness Programs	10		000000000000000010000000	2		1	0.00	0.00	2		2	2								
H3335	018	0	1	04	01	H3335_018_0	6	4	$0 Copayment	01	000000000000000000000000000100000000		2		1	0.00	0.00	2		2	2								
H3335	018	0	1	04	01	H3335_018_0	6	5	Preventive Services	01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H3335	018	0	1	04	01	H3335_018_0	6	3	$100 Copayment	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H3335	021	0	1	04	01	H3335_021_0	6	1	30% Coinsurance	11	011101111101101111111010111001111111	000000100000000100001000	2		2			2		2	1			30	30				
H3335	021	0	1	04	01	H3335_021_0	6	2	50% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			50	50				
H3335	021	0	1	04	01	H3335_021_0	6	6	Supplemental Education/Wellness Programs	10		000000000000000010000000	2		1	0.00	0.00	2		2	2								
H3335	021	0	1	04	01	H3335_021_0	6	4	$0 Copayment	01	000000000000000000000000000100000000		2		1	0.00	0.00	2		2	2								
H3335	021	0	1	04	01	H3335_021_0	6	5	Preventive Services	01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H3335	021	0	1	04	01	H3335_021_0	6	3	$100 Copayment	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H3335	032	0	1	04	01	H3335_032_0	6	1	30% Coinsurance	11	011101111101101111111010111011111111	000000100000000100001000	2		2			2		2	1			30	30				
H3335	032	0	1	04	01	H3335_032_0	6	5	Supplemental Education/Wellness Programs	10		000000000000000010000000	2		1	0.00	0.00	2		2	2								
H3335	032	0	1	04	01	H3335_032_0	6	4	$0 Copayment	01	000000000000000000000000000100000000		2		1	0.00	0.00	2		2	2								
H3335	032	0	1	04	01	H3335_032_0	6	3	$150 Copayment	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H3335	032	0	1	04	01	H3335_032_0	6	2	50% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			50	50				
H3335	037	0	1	04	01	H3335_037_0	6	6	$45 Copayment - Specialist Services	11	011100001101101000000000000000001111	000000000000000000001000	2		1	45.00	45.00	2		2	2								
H3335	037	0	1	04	01	H3335_037_0	6	5	Supplemental Education/Wellness Programs	10		000000000000000010000000	2		1	0.00	0.00	2		2	2								
H3335	037	0	1	04	01	H3335_037_0	6	4	$0 Copayment	01	000000000000000000000000000100000000		2		1	0.00	0.00	2		2	2								
H3335	037	0	1	04	01	H3335_037_0	6	3	$100 Copayment	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H3335	037	0	1	04	01	H3335_037_0	6	2	50% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			50	50				
H3335	037	0	1	04	01	H3335_037_0	6	1	30% Coinsurance	11	000001000000000111011010111001110000	000000100000000000000000	2		2			2		2	1			30	30				
H3335	037	0	1	04	01	H3335_037_0	6	7	$25 Copayment - PCP Services	11	000000110000000000000000000000000000	000000000000000100000000	2		1	25.00	25.00	2		2	2								
H3335	037	0	1	04	01	H3335_037_0	6	9	$20 Copayment - X-Ray	01	000000000000000000100000000000000000		2		1	20.00	20.00	2		2	2								
H3335	037	0	1	04	01	H3335_037_0	6	8	Medicare Covered Preventive Services	01	000000000000000000000000000010000000		2		1	0.00	25.00	2		2	1			30	30				
H3335	038	0	1	04	01	H3335_038_0	6	1	30% Coinsurance	11	000001000000000111011010111001110000	000000100000000000000000	2		2			2		2	1			30	30				
H3335	038	0	1	04	01	H3335_038_0	6	2	50% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			50	50				
H3335	038	0	1	04	01	H3335_038_0	6	3	$100 Copayment	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H3335	038	0	1	04	01	H3335_038_0	6	4	$0 Copayment	01	000000000000000000000000000100000000		2		1	0.00	0.00	2		2	2								
H3335	038	0	1	04	01	H3335_038_0	6	9	$20 Copayment - X-Ray	01	000000000000000000100000000000000000		2		1	20.00	20.00	2		2	2								
H3335	038	0	1	04	01	H3335_038_0	6	6	$45 Copayment - Specialist Services	11	011100001101101000000000000000001111	000000000000000000001000	2		1	45.00	45.00	2		2	2								
H3335	038	0	1	04	01	H3335_038_0	6	8	Medicare Covered Preventive Services	01	000000000000000000000000000010000000		2		1	0.00	25.00	2		2	1			30	30				
H3335	038	0	1	04	01	H3335_038_0	6	7	$25 Copayment - PCP Services	11	000000110000000000000000000000000000	000000000000000100000000	2		1	25.00	25.00	2		2	2								
H3335	038	0	1	04	01	H3335_038_0	6	5	Supplemental Education/Wellness Programs	10		000000000000000010000000	2		1	0.00	0.00	2		2	2								
H3335	041	0	1	04	01	H3335_041_0	5	2	50% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			50	50				
H3335	041	0	1	04	01	H3335_041_0	5	1	30% Coinsurance	11	011101111101101111111010111011111111	000000100000000100001000	2		2			2		2	1			30	30				
H3335	041	0	1	04	01	H3335_041_0	5	3	$100 Copayment	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H3335	041	0	1	04	01	H3335_041_0	5	4	$0 Copayment	01	000000000000000000000000000100000000		2		1	0.00	0.00	2		2	2								
H3335	041	0	1	04	01	H3335_041_0	5	5	Supplemental Education/Wellness Programs	10		000000000000000010000000	2		1	0.00	0.00	2		2	2								
H3335	042	0	1	04	01	H3335_042_0	5	1	30% Coinsurance	11	011101111101101111111010111011111111	000000100000000100001000	2		2			2		2	1			30	30				
H3335	042	0	1	04	01	H3335_042_0	5	2	50% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			50	50				
H3335	042	0	1	04	01	H3335_042_0	5	3	$100 Copayment	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H3335	042	0	1	04	01	H3335_042_0	5	4	$0 Copayment	01	000000000000000000000000000100000000		2		1	0.00	0.00	2		2	2								
H3335	042	0	1	04	01	H3335_042_0	5	5	Supplemental Education/Wellness Programs	10		000000000000000010000000	2		1	0.00	0.00	2		2	2								
H3335	043	0	1	04	01	H3335_043_0	5	2	50% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			50	50				
H3335	043	0	1	04	01	H3335_043_0	5	1	30% Coinsurance	11	011101111101101111111010111011111111	000000100000000100001000	2		2			2		2	1			30	30				
H3335	043	0	1	04	01	H3335_043_0	5	3	$100 Copayment	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H3335	043	0	1	04	01	H3335_043_0	5	5	Supplemental Education/Wellness Programs	10		000000000000000010000000	2		1	0.00	0.00	2		2	2								
H3335	043	0	1	04	01	H3335_043_0	5	4	$0 Copayment	01	000000000000000000000000000100000000		2		1	0.00	0.00	2		2	2								
H3335	044	0	1	04	01	H3335_044_0	5	1	30% Coinsurance	11	011101111101101111111010111011111111	000000100000000100001000	2		2			2		2	1			30	30				
H3335	044	0	1	04	01	H3335_044_0	5	2	50% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			50	50				
H3335	044	0	1	04	01	H3335_044_0	5	3	$100 Copayment	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H3335	044	0	1	04	01	H3335_044_0	5	4	$0 Copayment	01	000000000000000000000000000100000000		2		1	0.00	0.00	2		2	2								
H3335	044	0	1	04	01	H3335_044_0	5	5	Supplemental Education/Wellness Programs	10		000000000000000010000000	2		1	0.00	0.00	2		2	2								
H3335	045	0	1	04	01	H3335_045_0	5	1	30% Coinsurance	11	011101111101101111111010111011111111	000000100000000100001000	2		2			2		2	1			30	30				
H3335	045	0	1	04	01	H3335_045_0	5	2	50% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			50	50				
H3335	045	0	1	04	01	H3335_045_0	5	4	$0 Copayment	01	000000000000000000000000000100000000		2		1	0.00	0.00	2		2	2								
H3335	045	0	1	04	01	H3335_045_0	5	3	$100 Copayment	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H3335	045	0	1	04	01	H3335_045_0	5	5	Supplemental Education/Wellness Programs	10		000000000000000010000000	2		1	0.00	0.00	2		2	2								
H3335	051	0	1	04	01	H3335_051_0	7	1	30% Coinsurance	11	000001000000000111011010111001110000	000000100000000000000000	2		2			2		2	1			30	30				
H3335	051	0	1	04	01	H3335_051_0	7	2	50% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			50	50				
H3335	051	0	1	04	01	H3335_051_0	7	3	$100 Copayment	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H3335	051	0	1	04	01	H3335_051_0	7	4	$0 Copayment	01	000000000000000000000000000100000000		2		1	0.00	0.00	2		2	2								
H3335	051	0	1	04	01	H3335_051_0	7	9	$20 Copayment - X-Ray	01	000000000000000000100000000000000000		2		1	20.00	20.00	2		2	2								
H3335	051	0	1	04	01	H3335_051_0	7	6	$45 Copayment - Specialist Services	11	011100001101101000000000000000001111	000000000000000000001000	2		1	45.00	45.00	2		2	2								
H3335	051	0	1	04	01	H3335_051_0	7	7	$25 Copayment - PCP Services	11	000000110000000000000000000000000000	000000000000000100000000	2		1	25.00	25.00	2		2	2								
H3335	051	0	1	04	01	H3335_051_0	7	8	Medicare Covered Preventive Services	01	000000000000000000000000000010000000		2		1	0.00	25.00	2		2	1			30	30				
H3335	051	0	1	04	01	H3335_051_0	7	5	Supplemental Education/Wellness Programs	10		000000000000000010000000	2		1	0.00	0.00	2		2	2								
H3335	801	0	1	04	01	H3335_801_0	4	2	$0 Copayment	01	000001000000000000000000000000000000		2		1	0.00	0.00	2		2	2								
H3335	801	0	1	04	01	H3335_801_0	4	1	20% Coinsurance	01	011100111101101111111011111111111111		2		2			2		2	1			20	20				
H3335	801	0	1	04	01	H3335_801_0	4	3	35% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			35	35				
H3335	811	0	1	04	01	H3335_811_0	5	3	35% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			35	35				
H3335	811	0	1	04	01	H3335_811_0	5	2	$0 Copayment	01	000001000000000000000000000000000000		2		1	0.00	0.00	2		2	2								
H3335	811	0	1	04	01	H3335_811_0	5	1	20% Coinsurance	01	011100111101101111111011111111111111		2		2			2		2	1			20	20				
H3335	813	0	1	04	01	H3335_813_0	4	1	20% Coinsurance	01	011100111101101111111011111111111111		2		2			2		2	1			20	20				
H3335	813	0	1	04	01	H3335_813_0	4	2	$0 Copayment	01	000001000000000000000000000000000000		2		1	0.00	0.00	2		2	2								
H3335	813	0	1	04	01	H3335_813_0	4	3	35% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			35	35				
H3335	819	0	1	04	01	H3335_819_0	5	2	$0 Copayment	01	000001000000000000000000000000000000		2		1	0.00	0.00	2		2	2								
H3335	819	0	1	04	01	H3335_819_0	5	3	35% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			35	35				
H3335	819	0	1	04	01	H3335_819_0	5	1	20% Coinsurance	01	011100111101101111111011111111111111		2		2			2		2	1			20	20				
H3335	820	0	1	04	01	H3335_820_0	5	3	35% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			35	35				
H3335	820	0	1	04	01	H3335_820_0	5	2	$0 Copayment	01	000001000000000000000000000000000000		2		1	0.00	0.00	2		2	2								
H3335	820	0	1	04	01	H3335_820_0	5	1	20% Coinsurance	01	011100111101101111111011111111111111		2		2			2		2	1			20	20				
H3335	822	0	1	04	01	H3335_822_0	4	1	20% Coinsurance	01	011100111101101111111011111111111111		2		2			2		2	1			20	20				
H3335	822	0	1	04	01	H3335_822_0	4	3	35% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			35	35				
H3335	822	0	1	04	01	H3335_822_0	4	2	$0 Copayment	01	000001000000000000000000000000000000		2		1	0.00	0.00	2		2	2								
H3342	001	0	1	04	01	H3342_001_0	10	1	$0 Copayment Group	11	000000000000000000000010000000000110	000000100000000010001100	2		1	0.00	0.00	2		2	2								
H3342	001	0	1	04	01	H3342_001_0	10	10	20% Coinsurance Group	11	000000000000000000000000001100001000	000000000000000000100000	2		2			2		2	1			20	20				
H3342	001	0	1	04	01	H3342_001_0	10	11	25% Coinsurance Group	01	000000000000000000001000000000000000		2		2			2		2	1			25	25				
H3342	001	0	1	04	01	H3342_001_0	10	12	30% Coinsurance Group	01	000000000000000001000000110001110000		2		2			2		2	1			30	30				
H3342	001	0	1	04	01	H3342_001_0	10	13	50% Coinsurance Group	11	000000000000000000000000000000000001	000000000000000000000011	2		2			2		2	1			50	50				
H3342	001	0	1	04	01	H3342_001_0	10	2	$35 Copay Group	01	000000100000100000000000000000000000		2		1	35.00	35.00	2		2	2								
H3342	001	0	1	04	01	H3342_001_0	10	9	$35 Copay - 25% Coinsurance Group	01	000000000000000000010000000000000000		2		1	35.00	50.00	2		2	1			25	25				
H3342	001	0	1	04	01	H3342_001_0	10	4	$65 Copay Group	01	000001000000000000000000000000000000		2		1	65.00	65.00	2		2	2								
H3342	001	0	1	04	01	H3342_001_0	10	5	$100 Copay Group	01	000010000010010000000100000000000000		2		1	100.00	100.00	2		2	2								
H3342	001	0	1	04	01	H3342_001_0	10	6	$250 Copay Group	01	000000000000000000000001000000000000		2		1	250.00	250.00	2		2	2								
H3342	001	0	1	04	01	H3342_001_0	10	7	$0 - $100 Copay Group	01	000000000000000000000000000010000000		2		1	0.00	100.00	2		2	2								
H3342	001	0	1	04	01	H3342_001_0	10	8	$75 - $150 Copay Group	01	000000000000000010100000000000000000		2		1	75.00	150.00	2		1	2	2					1	35.00	50.00
H3342	001	0	1	04	01	H3342_001_0	10	3	$50 Copay Group	11	011100011101001100000000000000000100	000001000000000000000000	2		1	50.00	50.00	2		2	2								
H3342	002	0	1	04	01	H3342_002_0	9	7	$0 - $100 Copay Group	01	000000000000000000000000000010000000		2		1	0.00	100.00	2		2	2								
H3342	002	0	1	04	01	H3342_002_0	9	8	$75 - $150 Copay Group	01	000000000000000010100000000000000000		2		1	75.00	150.00	2		1	2	2					1	35.00	50.00
H3342	002	0	1	04	01	H3342_002_0	9	9	$35 Copay - 25% Coinsurance Group	01	000000000000000000010000000000000000		2		1	35.00	50.00	2		2	1			25	25				
H3342	002	0	1	04	01	H3342_002_0	9	1	$0 Copayment Group	11	000000000000000000000010000000000110	000000100000000010001100	2		1	0.00	0.00	2		2	2								
H3342	002	0	1	04	01	H3342_002_0	9	10	20% Coinsurance Group	11	000000000000000000000000001100001000	000000000000000000100000	2		2			2		2	1			20	20				
H3342	002	0	1	04	01	H3342_002_0	9	11	25% Coinsurance Group	01	000000000000000000001000000000000000		2		2			2		2	1			25	25				
H3342	002	0	1	04	01	H3342_002_0	9	12	30% Coinsurance Group	01	000000000000000001000000110001110000		2		2			2		2	1			30	30				
H3342	002	0	1	04	01	H3342_002_0	9	13	50% Coinsurance Group	11	000000000000000000000000000000000001	000000000000000000000011	2		2			2		2	1			50	50				
H3342	002	0	1	04	01	H3342_002_0	9	2	$35 Copay Group	01	000000100000100000000000000000000000		2		1	35.00	35.00	2		2	2								
H3342	002	0	1	04	01	H3342_002_0	9	3	$50 Copay Group	11	011100011101001100000000000000000100	000001000000000000000000	2		1	50.00	50.00	2		2	2								
H3342	002	0	1	04	01	H3342_002_0	9	4	$65 Copay Group	01	000001000000000000000000000000000000		2		1	65.00	65.00	2		2	2								
H3342	002	0	1	04	01	H3342_002_0	9	5	$100 Copay Group	01	000010000010010000000100000000000000		2		1	100.00	100.00	2		2	2								
H3342	002	0	1	04	01	H3342_002_0	9	6	$250 Copay Group	01	000000000000000000000001000000000000		2		1	250.00	250.00	2		2	2								
H3342	012	0	1	04	01	H3342_012_0	10	10	20% Coinsurance Grouping	01	000000000000000000000000001100001000		2		2			2		2	1			20	20				
H3342	012	0	1	04	01	H3342_012_0	10	1	$0 Copayment Group	11	000000000000000000000010000000000110	000000100000000010000000	2		1	0.00	0.00	2		2	2								
H3342	012	0	1	04	01	H3342_012_0	10	11	30% Coinsurance Group	01	000000000000000001001000110001110000		2		2			2		2	1			30	30				
H3342	012	0	1	04	01	H3342_012_0	10	2	$40 Copay Group	01	000000100000100000000000000000000000		2		1	40.00	40.00	2		2	2								
H3342	012	0	1	04	01	H3342_012_0	10	3	$65 Copay Group	11	011101011101001000000000000000000101	000001000000000000000000	2		1	65.00	65.00	2		2	2								
H3342	012	0	1	04	01	H3342_012_0	10	9	$40 Copay - 30% Coinsurance Group	01	000000000000000000010000000000000000		2		1	40.00	65.00	2		2	1			30	30				
H3342	012	0	1	04	01	H3342_012_0	10	5	$250 Copay Group	01	000000000000000000000001000000000000		2		1	250.00	250.00	2		2	2								
H3342	012	0	1	04	01	H3342_012_0	10	6	$0 - $100 Copay Group	01	000000000000000000000000000010000000		2		1	0.00	100.00	2		2	2								
H3342	012	0	1	04	01	H3342_012_0	10	7	$50 - $75 Copay Group	01	000000000000000100000000000000000000		2		1	50.00	75.00	2		2	2								
H3342	012	0	1	04	01	H3342_012_0	10	8	$150 - $200 Copay Group	01	000000000000000010100000000000000000		2		1	150.00	200.00	2		1	2	2					1	40.00	65.00
H3342	012	0	1	04	01	H3342_012_0	10	4	$100 Copay Group	01	000010000010010000000100000000000000		2		1	100.00	100.00	2		2	2								
H3342	013	0	1	04	01	H3342_013_0	11	7	$0 - $100 Copay Group	01	000000000000000000000000000010000000		2		1	0.00	100.00	2		2	2								
H3342	013	0	1	04	01	H3342_013_0	11	6	$50 - $75 Copay Group	01	000000000000000100000000000000000000		2		1	50.00	75.00	2		2	2								
H3342	013	0	1	04	01	H3342_013_0	11	5	$250 Copay Group	01	000000000000000000000001000000000000		2		1	250.00	250.00	2		2	2								
H3342	013	0	1	04	01	H3342_013_0	11	4	$100 Copay Group	01	000010000010010000000100000000000000		2		1	100.00	100.00	2		2	2								
H3342	013	0	1	04	01	H3342_013_0	11	3	$50 Copay Group	11	011101011101001000000000000000000100	000001000000000000000000	2		1	50.00	50.00	2		2	2								
H3342	013	0	1	04	01	H3342_013_0	11	2	$30 Copay Group	01	000000100000100000000000000000000000		2		1	30.00	30.00	2		2	2								
H3342	013	0	1	04	01	H3342_013_0	11	13	50% Coinsurance Group	11	000000000000000000000000000000000001	000000000000000000000011	2		2			2		2	1			50	50				
H3342	013	0	1	04	01	H3342_013_0	11	12	30% Coinsurance Group	01	000000000000000000000000110000000000		2		2			2		2	1			30	30				
H3342	013	0	1	04	01	H3342_013_0	11	1	$0 Copayment Group	11	000000000000000000000010000000000110	000000100000000010001100	2		1	0.00	0.00	2		2	2								
H3342	013	0	1	04	01	H3342_013_0	11	10	20% Coinsurance Grouping	11	000000000000000001000000001101111000	000000000000000000100000	2		2			2		2	1			20	20				
H3342	013	0	1	04	01	H3342_013_0	11	11	25% Coinsurance Group	01	000000000000000000001000000000000000		2		2			2		2	1			25	25				
H3342	013	0	1	04	01	H3342_013_0	11	9	$30 Copay - 25% Coinsurance Group	01	000000000000000000010000000000000000		2		1	30.00	50.00	2		2	1			25	25				
H3342	013	0	1	04	01	H3342_013_0	11	8	$125 - $150 Copay Group	01	000000000000000010100000000000000000		2		1	125.00	150.00	2		1	2	2					1	30.00	50.00
H3342	014	0	1	04	01	H3342_014_0	11	6	$50 - $75 Copay Group	01	000000000000000100000000000000000000		2		1	50.00	75.00	2		2	2								
H3342	014	0	1	04	01	H3342_014_0	11	5	$250 Copay Group	01	000000000000000000000001000000000000		2		1	250.00	250.00	2		2	2								
H3342	014	0	1	04	01	H3342_014_0	11	4	$100 Copay Group	01	000010000010010000000100000000000000		2		1	100.00	100.00	2		2	2								
H3342	014	0	1	04	01	H3342_014_0	11	3	$50 Copay Group	11	011101011101001000000000000000000100	000001000000000000000000	2		1	50.00	50.00	2		2	2								
H3342	014	0	1	04	01	H3342_014_0	11	2	$30 Copay Group	01	000000100000100000000000000000000000		2		1	30.00	30.00	2		2	2								
H3342	014	0	1	04	01	H3342_014_0	11	7	$0 - $100 Copay Group	01	000000000000000000000000000010000000		2		1	0.00	100.00	2		2	2								
H3342	014	0	1	04	01	H3342_014_0	11	13	50% Coinsurance Group	11	000000000000000000000000000000000001	000000000000000000000011	2		2			2		2	1			50	50				
H3342	014	0	1	04	01	H3342_014_0	11	8	$125 - $150 Copay Group	01	000000000000000010100000000000000000		2		1	125.00	150.00	2		1	2	2					1	30.00	50.00
H3342	014	0	1	04	01	H3342_014_0	11	1	$0 Copayment Group	11	000000000000000000000010000000000110	000000100000000010001100	2		1	0.00	0.00	2		2	2								
H3342	014	0	1	04	01	H3342_014_0	11	10	20% Coinsurance Grouping	11	000000000000000001000000001101111000	000000000000000000100000	2		2			2		2	1			20	20				
H3342	014	0	1	04	01	H3342_014_0	11	11	25% Coinsurance Group	01	000000000000000000001000000000000000		2		2			2		2	1			25	25				
H3342	014	0	1	04	01	H3342_014_0	11	12	30% Coinsurance Group	01	000000000000000000000000110000000000		2		2			2		2	1			30	30				
H3342	014	0	1	04	01	H3342_014_0	11	9	$30 Copay - 25% Coinsurance Group	01	000000000000000000010000000000000000		2		1	30.00	50.00	2		2	1			25	25				
H3342	015	0	1	04	01	H3342_015_0	11	9	$30 Copay - 25% Coinsurance Group	01	000000000000000000010000000000000000		2		1	30.00	50.00	2		2	1			25	25				
H3342	015	0	1	04	01	H3342_015_0	11	8	$125 - $150 Copay Group	01	000000000000000010100000000000000000		2		1	125.00	150.00	2		1	2	2					1	30.00	50.00
H3342	015	0	1	04	01	H3342_015_0	11	7	$0 - $100 Copay Group	01	000000000000000000000000000010000000		2		1	0.00	100.00	2		2	2								
H3342	015	0	1	04	01	H3342_015_0	11	4	$100 Copay Group	01	000010000010010000000100000000000000		2		1	100.00	100.00	2		2	2								
H3342	015	0	1	04	01	H3342_015_0	11	6	$50 - $75 Copay Group	01	000000000000000100000000000000000000		2		1	50.00	75.00	2		2	2								
H3342	015	0	1	04	01	H3342_015_0	11	5	$250 Copay Group	01	000000000000000000000001000000000000		2		1	250.00	250.00	2		2	2								
H3342	015	0	1	04	01	H3342_015_0	11	3	$50 Copay Group	11	011101011101001000000000000000000100	000001000000000000000000	2		1	50.00	50.00	2		2	2								
H3342	015	0	1	04	01	H3342_015_0	11	2	$30 Copay Group	01	000000100000100000000000000000000000		2		1	30.00	30.00	2		2	2								
H3342	015	0	1	04	01	H3342_015_0	11	1	$0 Copayment Group	11	000000000000000000000010000000000110	000000100000000010001100	2		1	0.00	0.00	2		2	2								
H3342	015	0	1	04	01	H3342_015_0	11	10	20% Coinsurance Grouping	11	000000000000000001000000001101111000	000000000000000000100000	2		2			2		2	1			20	20				
H3342	015	0	1	04	01	H3342_015_0	11	11	25% Coinsurance Group	01	000000000000000000001000000000000000		2		2			2		2	1			25	25				
H3342	015	0	1	04	01	H3342_015_0	11	12	30% Coinsurance Group	01	000000000000000000000000110000000000		2		2			2		2	1			30	30				
H3342	015	0	1	04	01	H3342_015_0	11	13	50% Coinsurance Group	11	000000000000000000000000000000000001	000000000000000000000011	2		2			2		2	1			50	50				
H3342	808	0	1	04	01	H3342_808_0	7	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H3342	808	0	1	04	01	H3342_808_0	7	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H3342	808	0	1	04	01	H3342_808_0	7	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H3342	809	0	1	04	01	H3342_809_0	5	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H3342	809	0	1	04	01	H3342_809_0	5	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H3342	809	0	1	04	01	H3342_809_0	5	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H3342	810	0	1	04	01	H3342_810_0	5	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H3342	810	0	1	04	01	H3342_810_0	5	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H3342	810	0	1	04	01	H3342_810_0	5	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H3344	005	0	1	04	01	H3344_005_0	6	1	$0 Cost share	11	000000000000000000000000000100000010	000000000001000010001000	2		2			2		2	2								
H3344	005	0	1	04	01	H3344_005_0	6	2	$40 copayment	01	000000100101100000000000000000000100		2		1	40.00	40.00	2		2	2								
H3344	005	0	1	04	01	H3344_005_0	6	3	$150 copayment	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H3344	005	0	1	04	01	H3344_005_0	6	4	30% coinsurance	11	011101001000001111111010001011111001	000000100000000000000000	2		2			2		2	1			30	30				
H3344	005	0	1	04	01	H3344_005_0	6	5	45% coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			45	45				
H3344	005	0	1	04	01	H3344_005_0	6	6	50% coinsurance	11	000000010000000000000000110000000000	000000000000000000100000	2		2			2		2	1			50	50				
H3344	006	0	1	04	01	H3344_006_0	9	2	$50 Specialist copayment	01	000000100101100000000000000000000100		2		1	50.00	50.00	2		2	2								
H3344	006	0	1	04	01	H3344_006_0	9	6	50% coinsurance	11	000000010000000000000000110000000000	000000000000000000100000	2		2			2		2	1			50	50				
H3344	006	0	1	04	01	H3344_006_0	9	5	45% Coinsurance	01	000010000010010000000100000000000000		2		2			2		2	1			45	45				
H3344	006	0	1	04	01	H3344_006_0	9	4	45% coinsurance	11	011101001000001111111010001011111001	000000100000000000000000	2		2			2		2	1			45	45				
H3344	006	0	1	04	01	H3344_006_0	9	3	$180 copayment	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H3344	006	0	1	04	01	H3344_006_0	9	1	$0 copayment	11	000000000000000000000000000100000010	000000000001000010001000	2		2			2		2	1			0	0				
H3344	801	0	1	04	01	H3344_801_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H3344	801	0	1	04	01	H3344_801_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H3344	801	0	1	04	01	H3344_801_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H3344	803	0	1	04	01	H3344_803_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H3344	803	0	1	04	01	H3344_803_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H3344	803	0	1	04	01	H3344_803_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H3344	804	0	1	04	01	H3344_804_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H3344	804	0	1	04	01	H3344_804_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H3344	804	0	1	04	01	H3344_804_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H3404	001	0	1	04	01	H3404_001_0	8	1	$100	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H3404	001	0	1	04	01	H3404_001_0	8	3	20% Coinsurance	11	011111111111111110111110111100011111	000000100000000000001000	2		2			2		2	1			20	20				
H3404	001	0	1	04	01	H3404_001_0	8	2	$0 Copay	01	000000000000000001000000000111100000		2		1	0.00	0.00	2		2	2								
H3404	002	0	1	04	01	H3404_002_0	9	7	$100 Copay	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H3404	002	0	1	04	01	H3404_002_0	9	1	$40 Copay	11	011110101111111000000100000000001101	000000000000000000001000	2		1	40.00	40.00	2		2	2								
H3404	002	0	1	04	01	H3404_002_0	9	2	20% Coinsurance	01	000000000000000110100000111000010010		2		2			2		2	1			20	20				
H3404	002	0	1	04	01	H3404_002_0	9	3	$125 Copay	01	000000000000000000011000000000000000		2		1	125.00	125.00	2		2	2								
H3404	002	0	1	04	01	H3404_002_0	9	4	No Cost Sharing	11	000001000000000001000010000111100000	000000100000000010000000	2		1	0.00	0.00	2		2	2								
H3404	002	0	1	04	01	H3404_002_0	9	5	$20 Copay	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H3404	002	0	1	04	01	H3404_002_0	9	6	$20-$40 Copay	01	000000000000100000000000000000000000		2		1	20.00	40.00	2		2	2								
H3404	801	0	1	04	01	H3404_801_0	3	3	No Cost Sharing	01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H3404	801	0	1	04	01	H3404_801_0	3	1	40% Coinsurance	01	000000000010010000000000000000000000		2		2			2		2	1			40	40				
H3404	801	0	1	04	01	H3404_801_0	3	2	20% Coinsurance	01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H3404	803	0	1	04	01	H3404_803_0	9	2	40% Coinsurance	01	000000000010010000000000000000000000		2		2			2		2	1			40	40				
H3404	803	0	1	04	01	H3404_803_0	9	3	20% Cost Sharing	01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H3404	803	0	1	04	01	H3404_803_0	9	1	No Cost Sharing	01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H3404	807	0	1	04	01	H3404_807_0	5	3	20% Coinsurance	01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H3404	807	0	1	04	01	H3404_807_0	5	1	No Cost Sharing	01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H3404	807	0	1	04	01	H3404_807_0	5	2	40% Coinsurance	01	000000000010010000000000000000000000		2		2			2		2	1			40	40				
H3404	808	0	1	04	01	H3404_808_0	4	1	No Cost Sharing	01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H3404	808	0	1	04	01	H3404_808_0	4	2	40% Coinsurance	01	000000000010010000000000000000000000		2		2			2		2	1			40	40				
H3404	808	0	1	04	01	H3404_808_0	4	3	20% Coinsurance	01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H3405	001	0	1	04	01	H3405_001_0	7	3		01	000000000000000000000000111000000000		2		2			2		2	1			40	40				
H3405	001	0	1	04	01	H3405_001_0	7	7		01	000000000000000000000000000010000000		2		1	0.00	0.00	2		2	1			35	35				
H3405	001	0	1	04	01	H3405_001_0	7	6		10		000000000000000010000000	2		2			2		2	1			50	50				
H3405	001	0	1	04	01	H3405_001_0	7	5		11	000000000000000000000010000000000010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H3405	001	0	1	04	01	H3405_001_0	7	4		01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H3405	001	0	1	04	01	H3405_001_0	7	2		01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H3405	001	0	1	04	01	H3405_001_0	7	1		11	011111111111111111111100000001111101	000000000000000100000000	2		2			2		2	1			35	35				
H3405	002	0	1	04	01	H3405_002_0	7	5		11	000000000000000000000010000000000010	000000100000000000001100	2		1	0.00	0.00	2		2	2								
H3405	002	0	1	04	01	H3405_002_0	7	4		01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H3405	002	0	1	04	01	H3405_002_0	7	3		01	000000000000000000000000111000000000		2		2			2		2	1			40	40				
H3405	002	0	1	04	01	H3405_002_0	7	2		01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H3405	002	0	1	04	01	H3405_002_0	7	1		11	011111111111111111111100000001111101	000000000000000100000000	2		2			2		2	1			30	30				
H3405	002	0	1	04	01	H3405_002_0	7	6		10		000000000000000010000000	2		2			2		2	1			50	50				
H3405	002	0	1	04	01	H3405_002_0	7	7		01	000000000000000000000000000010000000		2		1	0.00	0.00	2		2	1			30	30				
H3405	005	0	1	04	01	H3405_005_0	8	3		01	000000000000000000000000111000000000		2		2			2		2	1			40	40				
H3405	005	0	1	04	01	H3405_005_0	8	7		01	000000000000000000000000000010000000		2		1	0.00	0.00	2		2	1			30	30				
H3405	005	0	1	04	01	H3405_005_0	8	6		10		000000000000000010000000	2		2			2		2	1			50	50				
H3405	005	0	1	04	01	H3405_005_0	8	5		11	000000000000000000000010000000000010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H3405	005	0	1	04	01	H3405_005_0	8	4		01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H3405	005	0	1	04	01	H3405_005_0	8	2		01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H3405	005	0	1	04	01	H3405_005_0	8	1		11	011111111111111111111100000001111101	000000000000000100000000	2		2			2		2	1			30	30				
H3405	007	0	1	04	01	H3405_007_0	6	5		11	000000000000000000000010000000000010	000000100000000000001100	2		1	0.00	0.00	2		2	2								
H3405	007	0	1	04	01	H3405_007_0	6	4		01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H3405	007	0	1	04	01	H3405_007_0	6	3		01	000000000000000000000000111000000000		2		2			2		2	1			35	35				
H3405	007	0	1	04	01	H3405_007_0	6	6		10		000000000000000010000000	2		2			2		2	1			50	50				
H3405	007	0	1	04	01	H3405_007_0	6	7		01	000000000000000000000000000010000000		2		1	0.00	0.00	2		2	1			30	30				
H3405	007	0	1	04	01	H3405_007_0	6	2		01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H3405	007	0	1	04	01	H3405_007_0	6	1		11	011111111111111111111100000001111101	000000000000000100000000	2		2			2		2	1			30	30				
H3421	001	0	1	09	04	H3421_001_0	8	9	250	01	000000000000000000010000000000000000		2		1	250.00	250.00	2		2	2								
H3421	001	0	1	09	04	H3421_001_0	8	8	100	01	000000000000000000001001000000000000		2		1	100.00	100.00	2		2	2								
H3421	001	0	1	09	04	H3421_001_0	8	7	35-250	01	011100000000000000000100000000000000		2		1	35.00	250.00	2		2	2								
H3421	001	0	1	09	04	H3421_001_0	8	6	35	01	000000000010010000000000000000000000		2		1	35.00	35.00	2		2	2								
H3421	001	0	1	09	04	H3421_001_0	8	5	35	01	000000001101101000000000000000000000		2		1	35.00	35.00	2		2	2								
H3421	001	0	1	09	04	H3421_001_0	8	4	15	01	000000000000000100000000000000000000		2		1	15.00	15.00	2		1	2	2					1	10.00	35.00
H3421	001	0	1	09	04	H3421_001_0	8	1	110	01	000010000000000000000000000000000000		2		1	110.00	110.00	2		2	2								
H3421	001	0	1	09	04	H3421_001_0	8	2	20	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H3421	001	0	1	09	04	H3421_001_0	8	14	50	11	000000000000000000000000000000001111	000000000000000000101010	2		2			1	5000.00	2	1			50	50				
H3421	001	0	1	09	04	H3421_001_0	8	13	0	11	000001000000000000000010000011100000	000000100000000000000000	2		2			2		2	2								
H3421	001	0	1	09	04	H3421_001_0	8	12	20%	01	000000000000000011100000000000000000		2		2			2		1	1	2		20	20		1	10.00	35.00
H3421	001	0	1	09	04	H3421_001_0	8	11	20% no	01	000000000000000000000000001100010000		2		2			2		2	1			20	20				
H3421	001	0	1	09	04	H3421_001_0	8	10	30%	01	000000000000000000000000110000000000		2		2			2		2	1			30	30				
H3421	001	0	1	09	04	H3421_001_0	8	3	10 pcp	01	000000100000000000000000000000000000		2		1	10.00	10.00	2		2	2								
H3421	002	0	1	09	04	H3421_002_0	9	8	100	01	000000000000000000001000000000000000		2		1	100.00	100.00	2		2	2								
H3421	002	0	1	09	04	H3421_002_0	9	7	45-250	01	011100000000000000000100000000000000		2		1	45.00	250.00	2		2	2								
H3421	002	0	1	09	04	H3421_002_0	9	6	40	01	000000000010010000000000000000000000		2		1	40.00	40.00	2		2	2								
H3421	002	0	1	09	04	H3421_002_0	9	5	45	01	000000001101101000000000000000000000		2		1	45.00	45.00	2		2	2								
H3421	002	0	1	09	04	H3421_002_0	9	4	15	01	000000000000000100000000000000000000		2		1	15.00	15.00	2		1	2	2					1	20.00	45.00
H3421	002	0	1	09	04	H3421_002_0	9	3	20 pcp	01	000000100000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H3421	002	0	1	09	04	H3421_002_0	9	2	20	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H3421	002	0	1	09	04	H3421_002_0	9	15	150	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H3421	002	0	1	09	04	H3421_002_0	9	14	50	11	000000000000000000000000000000001111	000000000000000000001010	2		2			1	5000.00	2	1			50	50				
H3421	002	0	1	09	04	H3421_002_0	9	13	0	11	000001000000000000000010000011100000	000000100000000000000000	2		2			2		2	2								
H3421	002	0	1	09	04	H3421_002_0	9	12	20%	01	000000000000000011100000000000000000		2		2			2		1	1	2		20	20		1	20.00	45.00
H3421	002	0	1	09	04	H3421_002_0	9	11	20% no	01	000000000000000000000000001100010000		2		2			2		2	1			20	20				
H3421	002	0	1	09	04	H3421_002_0	9	10	30%	01	000000000000000000000000110000000000		2		2			2		2	1			30	30				
H3421	002	0	1	09	04	H3421_002_0	9	9	250	01	000000000000000000010000000000000000		2		1	250.00	250.00	2		2	2								
H3421	002	0	1	09	04	H3421_002_0	9	1	110	01	000010000000000000000000000000000000		2		1	110.00	110.00	2		2	2								
H3511	001	0	1	04	01	H3511_001_0	9	1	Group 1- 20% coinsurance	01	011110001010011111100110111100011111		2		2			2		2	1			20	20				
H3511	001	0	1	04	01	H3511_001_0	9	2	group 2 - $250 copay	01	000000000000000000011000000000000000		2		1	250.00	250.00	2		2	2								
H3511	001	0	1	04	01	H3511_001_0	9	3	group 3 - $75 copay	01	000000000000000000000001000000000000		2		1	75.00	75.00	2		2	2								
H3511	001	0	1	04	01	H3511_001_0	9	4	Group 4 - $40 copay	01	000000010101100000000000000000000000		2		1	40.00	40.00	2		2	2								
H3511	001	0	1	04	01	H3511_001_0	9	6	Group 6 - $0 copay	11	000001000000000000000000000011100000	000000000000000000001000	2		1	0.00	0.00	2		2	2								
H3511	001	0	1	04	01	H3511_001_0	9	5	Group 5- - $20 copay	01	000000100000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H3511	002	0	1	04	01	H3511_002_0	9	1	Group 1 - 20%	01	011110111111111111111111111100011111		2		2			2		2	1			20	20				
H3511	002	0	1	04	01	H3511_002_0	9	2	Group 2 - $0	11	000001000000000000000000000011100000	000000000000000000001000	2		2			2		2	2								
H3619	001	0	1	04	01	H3619_001_0	4	5		10		000000000000000010110000	2		2			2		2	1			50	50				
H3619	001	0	1	04	01	H3619_001_0	4	7		01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H3619	001	0	1	04	01	H3619_001_0	4	1		11	011111111111111111111100111001101101	000000000000000100000000	2		2			2		2	1			30	30				
H3619	001	0	1	04	01	H3619_001_0	4	2		01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
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H3619	020	0	1	04	01	H3619_020_0	6	2		11	011110111111111111101100000001101101	000000000000000100000000	2		2			2		2	1			30	30				
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H3813	003	0	1	04	01	H3813_003_0	4	7	$20 to $30 copayment	01	000000000010010000000100000000000000		2		1	20.00	30.00	2		2	2								
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H3813	004	0	1	04	01	H3813_004_0	4	5	20% coinsurance	01	000000000000000011111000110100010000		2		2			2		2	1			20	20				
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H3813	004	0	1	04	01	H3813_004_0	4	1	zero copayment	11	000001000000000100000010000011100110	000000000000000010000000	2		1	0.00	0.00	2		2	2								
H3813	004	0	1	04	01	H3813_004_0	4	2	$20 copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H3813	004	0	1	04	01	H3813_004_0	4	3	$35 copayment	11	011110101101101000000000000000001001	000000000000000000001000	2		1	35.00	35.00	2		2	2								
H3813	005	0	1	04	01	H3813_005_0	4	1	zero copayment	11	000001000000000100000010000011100110	000000000000000010000000	2		1	0.00	0.00	2		2	2								
H3813	005	0	1	04	01	H3813_005_0	4	2	$20 copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H3813	005	0	1	04	01	H3813_005_0	4	3	$35 copayment	11	011110101101101000000000000000001001	000000000000000000001000	2		1	35.00	35.00	2		2	2								
H3813	005	0	1	04	01	H3813_005_0	4	4	$100.00	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H3813	005	0	1	04	01	H3813_005_0	4	5	20% coinsurance	01	000000000000000011111000110100010000		2		2			2		2	1			20	20				
H3813	005	0	1	04	01	H3813_005_0	4	6	$20 - $30 copayment	01	000000000010010000000100000000000000		2		1	20.00	30.00	2		2	2								
H3813	005	0	1	04	01	H3813_005_0	4	7	$10 copayment supplies 20% shoes	01	000000000000000000000000001000000000		2		1	10.00	10.00	2		2	1			20	20				
H3813	006	0	1	04	01	H3813_006_0	5	8	20% coinsurance	01	000000000000000011100000110100010000		2		2			2		2	1			20	20				
H3813	006	0	1	04	01	H3813_006_0	5	9	$10 copayment/20% coinsurance	01	000000000000000000000000001000000000		2		1	10.00	10.00	2		2	1			20	20				
H3813	006	0	1	04	01	H3813_006_0	5	7	$20 to $30 copayment	01	000000000010010000000100000000000000		2		1	20.00	30.00	2		2	2								
H3813	006	0	1	04	01	H3813_006_0	5	6	$20 to $35 copayment	01	000000000000100000000000000000000000		2		1	20.00	35.00	2		2	2								
H3813	006	0	1	04	01	H3813_006_0	5	5	25% coinsurance	01	000000000000000000011000000000000000		2		2			2		2	1			25	25				
H3813	006	0	1	04	01	H3813_006_0	5	4	$250.00	01	000000000000000000000001000000000000		2		1	250.00	250.00	2		2	2								
H3813	006	0	1	04	01	H3813_006_0	5	3	$35 copayment	01	011110001000001000000000000000000000		2		1	35.00	35.00	2		2	2								
H3813	006	0	1	04	01	H3813_006_0	5	2	$20 copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H3813	006	0	1	04	01	H3813_006_0	5	11	$25 copayment	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H3813	006	0	1	04	01	H3813_006_0	5	10	$50 copayment	01	000000000101000000000000000000001001		2		1	50.00	50.00	2		2	2								
H3813	006	0	1	04	01	H3813_006_0	5	1	zero copayment	11	000001000000000100000010000011100110	000000000000000010000000	2		1	0.00	0.00	2		2	2								
H3813	802	0	1	04	01	H3813_802_0	1	1	20.00 Copayment	11	011110011111111000000100000000001001	000000000000000000001000	2		1	20.00	20.00	2		2	2								
H3813	802	0	1	04	01	H3813_802_0	1	2	zero copayment	11	000001000000000100000010000011100110	000000000000000010000000	2		1	0.00	0.00	2		2	2								
H3813	802	0	1	04	01	H3813_802_0	1	3	$125 copayment	01	000000000000000000011000000000000000		2		1	125.00	125.00	2		2	2								
H3813	802	0	1	04	01	H3813_802_0	1	4	$50 copayment	01	000000000000000000000001000000000000		2		1	50.00	50.00	2		2	2								
H3813	802	0	1	04	01	H3813_802_0	1	5	10% coinsurance	01	000000000000000011100000110100010000		2		2			2		2	1			10	10				
H3813	802	0	1	04	01	H3813_802_0	1	6	$15 copayment	01	000000100000000000000000000000000000		2		1	15.00	15.00	2		2	2								
H3813	802	0	1	04	01	H3813_802_0	1	7	$0 diabetic supplies 10% coinsurance	01	000000000000000000000000001000000000		2		1	0.00	0.00	2		2	1			10	10				
H3817	001	0	1	04	01	H3817_001_0	8	11	$500 Preventive Dental	10		000000000000000000100000	2		2			2		2	1			20	20				
H3817	001	0	1	04	01	H3817_001_0	8	10	$225	01	000000000000000000001000000000000000		2		1	225.00	225.00	2		2	2								
H3817	001	0	1	04	01	H3817_001_0	8	1	$35	11	011100111111111000000100000000001001	000000000000000000001000	2		1	35.00	35.00	2		2	2								
H3817	001	0	1	04	01	H3817_001_0	8	2	$100 copay	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H3817	001	0	1	04	01	H3817_001_0	8	9	$0 to $225	01	000000000000000000010000000000000000		2		1	0.00	225.00	2		2	2								
H3817	001	0	1	04	01	H3817_001_0	8	8	$0 to $35	01	000000000000000000000000000000000100		2		1	0.00	35.00	2		2	2								
H3817	001	0	1	04	01	H3817_001_0	8	7	$0 - no cost sharing	11	000010000000000100000010001011100010	000000100000000110000100	2		1	0.00	0.00	2		2	2								
H3817	001	0	1	04	01	H3817_001_0	8	6	10% to 20%	01	000000000000000000000000000000010000		2		2			2		2	1			10	20				
H3817	001	0	1	04	01	H3817_001_0	8	5	30% coinsurance	01	000000000000000000000000110000000000		2		2			2		2	1			30	30				
H3817	001	0	1	04	01	H3817_001_0	8	3	End-Stage Renal Disease	01	000000000000000000000000000100000000		2		2			2		2	1			10	10				
H3817	001	0	1	04	01	H3817_001_0	8	4	20%	01	000001000000000011100000000000000000		2		2			2		2	1			20	20				
H3817	002	0	1	04	01	H3817_002_0	9	8	$0 to $35	01	000000000000000000000000000000000100		2		1	0.00	35.00	2		2	2								
H3817	002	0	1	04	01	H3817_002_0	9	9	$0 to $225	01	000000000000000000010000000000000000		2		1	0.00	225.00	2		2	2								
H3817	002	0	1	04	01	H3817_002_0	9	1	$35	11	011100111111111000000100000000001001	000000000000000000001000	2		1	35.00	35.00	2		2	2								
H3817	002	0	1	04	01	H3817_002_0	9	10	$225	01	000000000000000000001000000000000000		2		1	225.00	225.00	2		2	2								
H3817	002	0	1	04	01	H3817_002_0	9	11	$500 Preventive Dental	10		000000000000000000100000	2		2			2		2	1			20	20				
H3817	002	0	1	04	01	H3817_002_0	9	2	$100 copay	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H3817	002	0	1	04	01	H3817_002_0	9	3	End-Stage Renal Disease	01	000000000000000000000000000100000000		2		2			2		2	1			10	10				
H3817	002	0	1	04	01	H3817_002_0	9	4	20%	01	000001000000000011100000000000000000		2		2			2		2	1			20	20				
H3817	002	0	1	04	01	H3817_002_0	9	5	30% coinsurance	01	000000000000000000000000110000000000		2		2			2		2	1			30	30				
H3817	002	0	1	04	01	H3817_002_0	9	6	10% to 20%	01	000000000000000000000000000000010000		2		2			2		2	1			10	20				
H3817	002	0	1	04	01	H3817_002_0	9	7	$0 - no cost sharing	11	000010000000000100000010001011100010	000000100000000110000100	2		1	0.00	0.00	2		2	2								
H3817	003	0	1	04	01	H3817_003_0	10	10	$200	01	000000000000000000001000000000000000		2		1	200.00	200.00	2		2	2								
H3817	003	0	1	04	01	H3817_003_0	10	8	$0 to $25	01	000000000000000000000000000000000100		2		1	0.00	25.00	2		2	2								
H3817	003	0	1	04	01	H3817_003_0	10	7	$0 - no cost sharing	11	000010000000000100000010001011100010	000000100000000110000100	2		1	0.00	0.00	2		2	2								
H3817	003	0	1	04	01	H3817_003_0	10	6	0% to 10%	01	000000000000000000000000000000010000		2		2			2		2	1			0	10				
H3817	003	0	1	04	01	H3817_003_0	10	5	20% coinsurance	01	000000000000000011000000110000000000		2		2			2		2	1			20	20				
H3817	003	0	1	04	01	H3817_003_0	10	4	10%	01	000001000000000000100000000000000000		2		2			2		2	1			10	10				
H3817	003	0	1	04	01	H3817_003_0	10	3	End-Stage Renal Disease	01	000000000000000000000000000100000000		2		2			2		2	1			10	10				
H3817	003	0	1	04	01	H3817_003_0	10	2	$100 copay	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H3817	003	0	1	04	01	H3817_003_0	10	1	$25	11	011100111111111000000100000000001001	000000000000000000001000	2		1	25.00	25.00	2		2	2								
H3817	003	0	1	04	01	H3817_003_0	10	9	$0 to $200	01	000000000000000000010000000000000000		2		1	0.00	200.00	2		2	2								
H3817	003	0	1	04	01	H3817_003_0	10	11	$500 Preventive Dental	10		000000000000000000100000	2		2			2		2	1			30	30				
H3817	801	0	1	04	01	H3817_801_0	5	4	20%	01	011110111101101011111101111101111101		2		2			2		2	1			20	20				
H3817	801	0	1	04	01	H3817_801_0	5	3	0% to 20%	01	000000000000000100000000000000000000		2		2			2		2	1			0	20				
H3817	801	0	1	04	01	H3817_801_0	5	2	35%	01	000000000010010000000000000000000000		2		2			2		2	1			40	40				
H3817	801	0	1	04	01	H3817_801_0	5	1	$0	01	000001000000000000000010000010000010		2		1	0.00	0.00	2		2	2								
H3817	802	0	1	04	01	H3817_802_0	5	3	0% to 20%	01	000000000000000100000000000000000000		2		2			2		2	1			0	20				
H3817	802	0	1	04	01	H3817_802_0	5	2	35%	01	000000000010010000000000000000000000		2		2			2		2	1			40	40				
H3817	802	0	1	04	01	H3817_802_0	5	1	$0	01	000001000000000000000010000010000010		2		1	0.00	0.00	2		2	2								
H3817	802	0	1	04	01	H3817_802_0	5	4	20%	01	011110111101101011111101111101111101		2		2			2		2	1			20	20				
H3832	001	0	1	04	01	H3832_001_0	10	9	Group 9 - 0%-30%	01	000000000000000000000000001000000000		2		2			2		2	1			0	30				
H3832	001	0	1	04	01	H3832_001_0	10	8	Group 8 - $150	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H3832	001	0	1	04	01	H3832_001_0	10	7	Group 7 - $35-$45	01	000000000010010000000100000000000000		2		1	35.00	45.00	2		2	2								
H3832	001	0	1	04	01	H3832_001_0	10	6	Group 6 - $21	01	000000000000000000100000000000000000		2		1	21.00	21.00	2		2	2								
H3832	001	0	1	04	01	H3832_001_0	10	1	Group 1 - 30%	01	000001000000000011011000110000010000		2		2			2		2	1			30	30				
H3832	001	0	1	04	01	H3832_001_0	10	4	Group 4 - $45	01	000010000000000000000000000000000000		2		1	45.00	45.00	2		2	2								
H3832	001	0	1	04	01	H3832_001_0	10	3	Group 3 - $35	11	011100111101101000000000000000001101	000000000000000000001000	2		1	35.00	35.00	2		2	2								
H3832	001	0	1	04	01	H3832_001_0	10	2	Group 2 - $0	11	000000000000000000000010000011100010	000000000000000000000100	2		1	0.00	0.00	2		2	2								
H3832	001	0	1	04	01	H3832_001_0	10	10	Group 10 - 20%	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H3832	001	0	1	04	01	H3832_001_0	10	5	Group 5 - $0-$10	01	000000000000000100000000000000000000		2		1	0.00	10.00	2		2	2								
H3832	006	0	1	04	01	H3832_006_0	8	7	Group 7 - $0-$30	01	000000000000000100000000000000000000		2		1	0.00	30.00	2		2	2								
H3832	006	0	1	04	01	H3832_006_0	8	8	Group 8 - 20%	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H3832	006	0	1	04	01	H3832_006_0	8	6	Group 6 - 0%-25%	01	000000000000000000000000001000000000		2		2			2		2	1			0	25				
H3832	006	0	1	04	01	H3832_006_0	8	5	Group 5 - 25%	01	000000000000000000000000110000000000		2		2			2		2	1			25	25				
H3832	006	0	1	04	01	H3832_006_0	8	4	Group 4 - $100	01	000000000000000000011001000000000000		2		1	100.00	100.00	2		2	2								
H3832	006	0	1	04	01	H3832_006_0	8	3	Group 3 - $30	11	011110111111111010100100000000001101	000000000000000000001000	2		1	30.00	30.00	2		2	2								
H3832	006	0	1	04	01	H3832_006_0	8	2	Group 2 - $0	11	000000000000000001000010000011100010	000000000000000000000100	2		1	0.00	0.00	2		2	2								
H3832	006	0	1	04	01	H3832_006_0	8	1	Group 1 - 30%	01	000001000000000000000000000000010000		2		2			2		2	1			30	30				
H3832	801	0	1	04	01	H3832_801_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H3832	801	0	1	04	01	H3832_801_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H3832	801	0	1	04	01	H3832_801_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H3832	802	0	1	04	01	H3832_802_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H3832	802	0	1	04	01	H3832_802_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H3832	802	0	1	04	01	H3832_802_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H3832	805	0	1	04	01	H3832_805_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H3832	805	0	1	04	01	H3832_805_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H3832	805	0	1	04	01	H3832_805_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H3832	806	0	1	04	01	H3832_806_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H3832	806	0	1	04	01	H3832_806_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H3832	806	0	1	04	01	H3832_806_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H3909	001	0	1	04	01	H3909_001_0	7	4	Group4	10		000000000000000110000000	2		1	0.00	0.00	2		2	2								
H3909	001	0	1	04	01	H3909_001_0	7	3	Group3	01	000000000000000000000001000000000000		2		1	75.00	75.00	2		2	2								
H3909	001	0	1	04	01	H3909_001_0	7	2	Group2	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H3909	001	0	1	04	01	H3909_001_0	7	1	Group1	11	011111111111111111111110111011111111	000000100000000000000000	2		2			2		2	1			30	30				
H3909	007	0	1	04	01	H3909_007_0	3	3	Group3	01	000000000000000000000001000000000000		2		1	75.00	75.00	2		2	2								
H3909	007	0	1	04	01	H3909_007_0	3	4	Group4	10		000000000000000110000000	2		1	0.00	0.00	2		2	2								
H3909	007	0	1	04	01	H3909_007_0	3	2	Group2	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H3909	007	0	1	04	01	H3909_007_0	3	1	Group1	11	011111111111111111111110111011111111	000000100000000000000000	2		2			2		2	1			30	30				
H3909	801	0	1	04	01	H3909_801_0	3	1		01	011101111101101111111111111111111111		2		2			2		2	1			30	30				
H3909	801	0	1	04	01	H3909_801_0	3	2	Group #2	01	000010000010010000000000000000000000		2		2			2		2	1			40	40				
H3909	802	0	1	04	01	H3909_802_0	3	2	Group #2	01	000010000010010000000000000000000000		2		2			2		2	1			40	40				
H3909	802	0	1	04	01	H3909_802_0	3	1		01	011101111101101111111111111111111111		2		2			2		2	1			30	30				
H3912	001	0	1	04	01	H3912_001_0	6	2	Group 2	11	000000000000000000000000000000000010	000000000000000000110100	2		1	0.00	0.00	2		2	2								
H3912	001	0	1	04	01	H3912_001_0	6	3	Group 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H3912	001	0	1	04	01	H3912_001_0	6	4	Group 4	10		000000010000000000000000	2		2			2		2	1			75	75				
H3912	001	0	1	04	01	H3912_001_0	6	5	Group 5	01	000000000000000100000000000010000000		2		2			2		2	1			0	30				
H3912	001	0	1	04	01	H3912_001_0	6	1	Group 1	11	011111111111111011111111111001111101	000001100000000000001000	2		2			2		2	1			30	30				
H3916	001	0	1	04	01	H3916_001_0	5	10	Group 10	01	000000100000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H3916	001	0	1	04	01	H3916_001_0	5	1	Group 1	11	000000000000000100000000000000000100	000000000000000000001000	2		2			2		1	1	2		0	30		1	30.00	40.00
H3916	001	0	1	04	01	H3916_001_0	5	11	Group 11	01	000000000100000000000000000000000000		2		1	40.00	40.00	2		2	2								
H3916	001	0	1	04	01	H3916_001_0	5	12	Group 12	01	000000000000000000000000000100010000		2		2			2		2	1			0	30				
H3916	001	0	1	04	01	H3916_001_0	5	7	Group 7	01	000000000000000000000000000011000000		2		2			2		2	1			0	0				
H3916	001	0	1	04	01	H3916_001_0	5	8	Group 8	01	000000000000000000000000100000000000		2		2			2		2	1			0	50				
H3916	001	0	1	04	01	H3916_001_0	5	6	Group 6	11	000000000000000000000000011000000000	000000010000000000100000	2		2			2		2	1			50	50				
H3916	001	0	1	04	01	H3916_001_0	5	9	Group 9	10		000000000000000010000000	2		2			1	500.00	2	1			50	50				
H3916	001	0	1	04	01	H3916_001_0	5	5	Group 5	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	1			30	30				
H3916	001	0	1	04	01	H3916_001_0	5	4	Group 4	11	011111011011111000011110000000000011	000011100000000000000110	2		2			2		2	1			30	30				
H3916	001	0	1	04	01	H3916_001_0	5	3	Group 3	01	000000000000000000000000000000100000		2		2			2		1	1	2		0	0		1	30.00	40.00
H3916	001	0	1	04	01	H3916_001_0	5	2	Group 2	01	000000000000000011100000000000000000		2		2			2		1	1	2		30	30		1	30.00	40.00
H3916	001	0	1	04	01	H3916_001_0	5	14	Group 14	11	000000000000000000000000000000001000	000000000000000000010000	2		2			2		2	1			30	50				
H3916	001	0	1	04	01	H3916_001_0	5	13	Group 13	10		000000000000000000000001	1	500.00	2			2		2	1			0	0				
H3916	002	0	1	04	01	H3916_002_0	5	3	Group 3	01	000000000000000000000000000000100000		2		2			2		1	1	2		0	0		1	30.00	40.00
H3916	002	0	1	04	01	H3916_002_0	5	4	Group 4	11	011111011011111000011110000000000011	000011100000000000000110	2		2			2		2	1			30	30				
H3916	002	0	1	04	01	H3916_002_0	5	5	Group 5	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	1			30	30				
H3916	002	0	1	04	01	H3916_002_0	5	6	Group 6	11	000000000000000000000000011000000000	000000010000000000100000	2		2			2		2	1			50	50				
H3916	002	0	1	04	01	H3916_002_0	5	7	Group 7	01	000000000000000000000000000011000000		2		2			2		2	1			0	0				
H3916	002	0	1	04	01	H3916_002_0	5	8	Group 8	01	000000000000000000000000100000000000		2		2			2		2	1			0	50				
H3916	002	0	1	04	01	H3916_002_0	5	1	Group 1	11	000000000000000100000000000000000100	000000000000000000001000	2		2			2		1	1	2		0	30		1	30.00	40.00
H3916	002	0	1	04	01	H3916_002_0	5	2	Group 2	01	000000000000000011100000000000000000		2		2			2		1	1	2		30	30		1	30.00	40.00
H3916	002	0	1	04	01	H3916_002_0	5	14	Group 14	11	000000000000000000000000000000001000	000000000000000000010000	2		2			2		2	1			30	50				
H3916	002	0	1	04	01	H3916_002_0	5	13	Group 13	10		000000000000000000000001	1	500.00	2			2		2	1			0	0				
H3916	002	0	1	04	01	H3916_002_0	5	12	Group 12	01	000000000000000000000000000100010000		2		2			2		2	1			0	30				
H3916	002	0	1	04	01	H3916_002_0	5	11	Group 11	01	000000000100000000000000000000000000		2		1	40.00	40.00	2		2	2								
H3916	002	0	1	04	01	H3916_002_0	5	10	Group 10	01	000000100000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H3916	002	0	1	04	01	H3916_002_0	5	9	Group 9	10		000000000000000010000000	2		2			1	500.00	2	1			50	50				
H3916	005	0	1	04	01	H3916_005_0	6	14	Group 14	11	000000000000000000000000000000001000	000000000000000000010000	2		2			2		2	1			30	50				
H3916	005	0	1	04	01	H3916_005_0	6	13	Group 13	10		000000000000000000000001	1	1000.00	2			2		2	1			0	0				
H3916	005	0	1	04	01	H3916_005_0	6	12	Group 12	01	000000000000000000000000000100010000		2		2			2		2	1			0	30				
H3916	005	0	1	04	01	H3916_005_0	6	11	Group 11	01	000000000100000000000000000000000000		2		1	40.00	40.00	2		2	2								
H3916	005	0	1	04	01	H3916_005_0	6	9	Group 9	10		000000000000000010000000	2		2			1	500.00	2	1			50	50				
H3916	005	0	1	04	01	H3916_005_0	6	8	Group 8	01	000000000000000000000000100000000000		2		2			2		2	1			0	50				
H3916	005	0	1	04	01	H3916_005_0	6	7	Group 7	01	000000000000000000000000000011000000		2		2			2		2	1			0	0				
H3916	005	0	1	04	01	H3916_005_0	6	6	Group 6	11	000000000000000000000000011000000000	000000010000000000100000	2		2			2		2	1			50	50				
H3916	005	0	1	04	01	H3916_005_0	6	5	Group 5	01	000000000000000000000001000000000000		2		1	75.00	75.00	2		2	1			30	30				
H3916	005	0	1	04	01	H3916_005_0	6	10	Group 10	01	000000100000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H3916	005	0	1	04	01	H3916_005_0	6	1	Group 1	11	000000000000000100000000000000000100	000000000000000000001000	2		2			2		1	1	2		0	30		1	30.00	40.00
H3916	005	0	1	04	01	H3916_005_0	6	2	Group 2	01	000000000000000011100000000000000000		2		2			2		1	1	2		30	30		1	30.00	40.00
H3916	005	0	1	04	01	H3916_005_0	6	3	Group 3	01	000000000000000000000000000000100000		2		2			2		1	1	2		0	0		1	30.00	40.00
H3916	005	0	1	04	01	H3916_005_0	6	4	Group 4	11	011111011011111000011110000000000011	000011100000000000000110	2		2			2		2	1			30	30				
H3916	012	0	1	04	01	H3916_012_0	4	1	Group 1	11	000000000000000100000000000000000100	000000000000000000001000	2		2			2		1	1	2		0	30		1	30.00	45.00
H3916	012	0	1	04	01	H3916_012_0	4	10	Group 10	01	000000100000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H3916	012	0	1	04	01	H3916_012_0	4	11	Group 11	01	000000000100000000000000000000000000		2		1	45.00	45.00	2		2	2								
H3916	012	0	1	04	01	H3916_012_0	4	12	Group 12	01	000000000000000000000000000100010000		2		2			2		2	1			0	30				
H3916	012	0	1	04	01	H3916_012_0	4	13	Group 13	10		000000000000000000000001	1	500.00	2			2		2	1			0	0				
H3916	012	0	1	04	01	H3916_012_0	4	2	Group 2	01	000000000000000011100000000000000000		2		2			2		1	1	2		30	30		1	30.00	45.00
H3916	012	0	1	04	01	H3916_012_0	4	3	Group 3	01	000000000000000000000000000000100000		2		2			2		1	1	2		0	0		1	30.00	45.00
H3916	012	0	1	04	01	H3916_012_0	4	4	Group 4	11	011111011011111000011110000000001011	000011100000000000000110	2		2			2		2	1			30	30				
H3916	012	0	1	04	01	H3916_012_0	4	5	Group 5	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	1			30	30				
H3916	012	0	1	04	01	H3916_012_0	4	6	Group 6	11	000000000000000000000000011000000000	000000010000000000000000	2		2			2		2	1			50	50				
H3916	012	0	1	04	01	H3916_012_0	4	7	Group 7	01	000000000000000000000000000011000000		2		2			2		2	1			0	0				
H3916	012	0	1	04	01	H3916_012_0	4	8	Group 8	01	000000000000000000000000100000000000		2		2			2		2	1			0	50				
H3916	012	0	1	04	01	H3916_012_0	4	9	Group 9	10		000000000000000010000000	2		2			1	500.00	2	1			50	50				
H3916	015	0	1	04	01	H3916_015_0	5	9	Group 9	10		000000000000000010000000	2		2			1	500.00	2	1			50	50				
H3916	015	0	1	04	01	H3916_015_0	5	8	Group 8	01	000000000000000000000000100000000000		2		2			2		2	1			0	50				
H3916	015	0	1	04	01	H3916_015_0	5	7	Group 7	01	000000000000000000000000000011000000		2		2			2		2	1			0	0				
H3916	015	0	1	04	01	H3916_015_0	5	6	Group 6	11	000000000000000000000000011000000000	000000010000000000000000	2		2			2		2	1			50	50				
H3916	015	0	1	04	01	H3916_015_0	5	5	Group 5	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	1			30	30				
H3916	015	0	1	04	01	H3916_015_0	5	4	Group 4	11	011111011011111000011110000000001011	000011100000000000000110	2		2			2		2	1			30	30				
H3916	015	0	1	04	01	H3916_015_0	5	11	Group 11	01	000000000100000000000000000000000000		2		1	45.00	45.00	2		2	2								
H3916	015	0	1	04	01	H3916_015_0	5	2	Group 2	01	000000000000000011100000000000000000		2		2			2		1	1	2		30	30		1	30.00	45.00
H3916	015	0	1	04	01	H3916_015_0	5	13	Group 13	10		000000000000000000000001	1	500.00	2			2		2	1			0	0				
H3916	015	0	1	04	01	H3916_015_0	5	12	Group 12	01	000000000000000000000000000100010000		2		2			2		2	1			0	30				
H3916	015	0	1	04	01	H3916_015_0	5	1	Group 1	11	000000000000000100000000000000000100	000000000000000000001000	2		2			2		1	1	2		0	30		1	30.00	45.00
H3916	015	0	1	04	01	H3916_015_0	5	10	Group 10	01	000000100000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H3916	015	0	1	04	01	H3916_015_0	5	3	Group 3	01	000000000000000000000000000000100000		2		2			2		1	1	2		0	0		1	30.00	45.00
H3916	018	0	1	04	01	H3916_018_0	5	6	Group 6	11	000000000000000000000000011000000000	000000010000000000000000	2		2			2		2	1			50	50				
H3916	018	0	1	04	01	H3916_018_0	5	7	Group 7	01	000000000000000000000000000011000000		2		2			2		2	1			0	0				
H3916	018	0	1	04	01	H3916_018_0	5	5	Group 5	01	000000000000000000000001000000000000		2		1	125.00	125.00	2		2	1			30	30				
H3916	018	0	1	04	01	H3916_018_0	5	4	Group 4	11	011111011011111000011110000000001011	000011100000000000000110	2		2			2		2	1			30	30				
H3916	018	0	1	04	01	H3916_018_0	5	3	Group 3	01	000000000000000000000000000000100000		2		2			2		1	1	2		0	0		1	30.00	50.00
H3916	018	0	1	04	01	H3916_018_0	5	2	Group 2	01	000000000000000011100000000000000000		2		2			2		1	1	2		30	30		1	30.00	50.00
H3916	018	0	1	04	01	H3916_018_0	5	13	Group 13	10		000000000000000000000001	1	500.00	2			2		2	1			0	0				
H3916	018	0	1	04	01	H3916_018_0	5	12	Group 12	01	000000000000000000000000000100010000		2		2			2		2	1			0	30				
H3916	018	0	1	04	01	H3916_018_0	5	11	Group 11	01	000000000100000000000000000000000000		2		1	50.00	50.00	2		2	2								
H3916	018	0	1	04	01	H3916_018_0	5	10	Group 10	01	000000100000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H3916	018	0	1	04	01	H3916_018_0	5	8	Group 8	01	000000000000000000000000100000000000		2		2			2		2	1			0	50				
H3916	018	0	1	04	01	H3916_018_0	5	9	Group 9	10		000000000000000010000000	2		2			1	500.00	2	1			50	50				
H3916	018	0	1	04	01	H3916_018_0	5	1	Group 1	11	000000000000000100000000000000000100	000000000000000000001000	2		2			2		1	1	2		0	30		1	30.00	50.00
H3916	019	0	1	04	01	H3916_019_0	8	9	Group 9	10		000000000000000000000001	1	500.00	2			2		2	1			0	0				
H3916	019	0	1	04	01	H3916_019_0	8	1	Group 1	11	000000000000000100000000000000000100	000000000000000000001000	2		2			2		1	1	1	30	0	30	30	2		
H3916	019	0	1	04	01	H3916_019_0	8	10	Group 10	01	000000000000000000000000000100010000		2		2			2		2	1			0	30				
H3916	019	0	1	04	01	H3916_019_0	8	2	Group 2	01	000000000000000011100000000000000000		2		2			2		1	1	1	30	30	30	30	2		
H3916	019	0	1	04	01	H3916_019_0	8	8	Group 8	01	000000000000000000000000100000000000		2		2			2		2	1			0	50				
H3916	019	0	1	04	01	H3916_019_0	8	4	Group 4	11	011111111111111000011110000000001011	000000100000000000000110	2		2			2		2	1			30	30				
H3916	019	0	1	04	01	H3916_019_0	8	5	Group 5	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	1			30	30				
H3916	019	0	1	04	01	H3916_019_0	8	6	Group 6	11	000000000000000000000000011000000000	000000010000000010000000	2		2			2		2	1			50	50				
H3916	019	0	1	04	01	H3916_019_0	8	7	Group 7	01	000000000000000000000000000011000000		2		2			2		2	1			0	0				
H3916	019	0	1	04	01	H3916_019_0	8	3	Group 3	01	000000000000000000000000000000100000		2		2			2		1	1	1	30	0	0	30	2		
H3916	020	0	1	04	01	H3916_020_0	8	5	Group 5	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	1			30	30				
H3916	020	0	1	04	01	H3916_020_0	8	6	Group 6	11	000000000000000000000000011000000000	000000010000000010000000	2		2			2		2	1			50	50				
H3916	020	0	1	04	01	H3916_020_0	8	7	Group 7	01	000000000000000000000000000011000000		2		2			2		2	1			0	0				
H3916	020	0	1	04	01	H3916_020_0	8	8	Group 8	01	000000000000000000000000100000000000		2		2			2		2	1			0	50				
H3916	020	0	1	04	01	H3916_020_0	8	9	Group 9	10		000000000000000000000001	1	500.00	2			2		2	1			0	0				
H3916	020	0	1	04	01	H3916_020_0	8	1	Group 1	11	000000000000000100000000000000000100	000000000000000000001000	2		2			2		1	1	1	30	0	30	30	2		
H3916	020	0	1	04	01	H3916_020_0	8	10	Group 10	01	000000000000000000000000000100010000		2		2			2		2	1			0	30				
H3916	020	0	1	04	01	H3916_020_0	8	2	Group 2	01	000000000000000011100000000000000000		2		2			2		1	1	1	30	30	30	30	2		
H3916	020	0	1	04	01	H3916_020_0	8	3	Group 3	01	000000000000000000000000000000100000		2		2			2		1	1	1	30	0	0	30	2		
H3916	020	0	1	04	01	H3916_020_0	8	4	Group 4	11	011111111111111000011110000000001011	000000100000000000000110	2		2			2		2	1			30	30				
H3916	022	0	1	04	01	H3916_022_0	5	12	Group 12	01	000000000000000000000000000100010000		2		2			2		2	1			0	30				
H3916	022	0	1	04	01	H3916_022_0	5	11	Group 11	01	000000000100000000000000000000000000		2		1	50.00	50.00	2		2	2								
H3916	022	0	1	04	01	H3916_022_0	5	10	Group 10	01	000000100000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H3916	022	0	1	04	01	H3916_022_0	5	1	Group 1	11	000000000000000100000000000000000100	000000000000000000001000	2		2			2		1	1	2		0	30		1	30.00	50.00
H3916	022	0	1	04	01	H3916_022_0	5	13	Group 13	10		000000000000000000000001	1	500.00	2			2		2	1			0	0				
H3916	022	0	1	04	01	H3916_022_0	5	2	Group 2	01	000000000000000011100000000000000000		2		2			2		1	1	2		30	30		1	30.00	50.00
H3916	022	0	1	04	01	H3916_022_0	5	9	Group 9	10		000000000000000010000000	2		2			1	500.00	2	1			50	50				
H3916	022	0	1	04	01	H3916_022_0	5	4	Group 4	11	011111011011111000011110000000001011	000011100000000000000110	2		2			2		2	1			30	30				
H3916	022	0	1	04	01	H3916_022_0	5	5	Group 5	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	1			30	30				
H3916	022	0	1	04	01	H3916_022_0	5	6	Group 6	11	000000000000000000000000011000000000	000000010000000000000000	2		2			2		2	1			50	50				
H3916	022	0	1	04	01	H3916_022_0	5	7	Group 7	01	000000000000000000000000000011000000		2		2			2		2	1			0	0				
H3916	022	0	1	04	01	H3916_022_0	5	8	Group 8	01	000000000000000000000000100000000000		2		2			2		2	1			0	50				
H3916	022	0	1	04	01	H3916_022_0	5	3	Group 3	01	000000000000000000000000000000100000		2		2			2		1	1	2		0	0		1	30.00	50.00
H3916	024	0	1	04	01	H3916_024_0	5	12	Group 12	01	000000000000000000000000000100010000		2		2			2		2	1			0	30				
H3916	024	0	1	04	01	H3916_024_0	5	11	Group 11	01	000000000100000000000000000000000000		2		1	50.00	50.00	2		2	2								
H3916	024	0	1	04	01	H3916_024_0	5	10	Group 10	01	000000100000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H3916	024	0	1	04	01	H3916_024_0	5	1	Group 1	11	000000000000000100000000000000000100	000000000000000000001000	2		2			2		1	1	2		0	30		1	30.00	50.00
H3916	024	0	1	04	01	H3916_024_0	5	13	Group 13	10		000000000000000000000001	1	500.00	2			2		2	1			0	0				
H3916	024	0	1	04	01	H3916_024_0	5	9	Group 9	10		000000000000000010000000	2		2			1	500.00	2	1			50	50				
H3916	024	0	1	04	01	H3916_024_0	5	8	Group 8	01	000000000000000000000000100000000000		2		2			2		2	1			0	50				
H3916	024	0	1	04	01	H3916_024_0	5	7	Group 7	01	000000000000000000000000000011000000		2		2			2		2	1			0	0				
H3916	024	0	1	04	01	H3916_024_0	5	6	Group 6	11	000000000000000000000000011000000000	000000010000000000000000	2		2			2		2	1			50	50				
H3916	024	0	1	04	01	H3916_024_0	5	5	Group 5	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	1			30	30				
H3916	024	0	1	04	01	H3916_024_0	5	4	Group 4	11	011111011011111000011110000000001011	000011100000000000000110	2		2			2		2	1			30	30				
H3916	024	0	1	04	01	H3916_024_0	5	3	Group 3	01	000000000000000000000000000000100000		2		2			2		1	1	2		0	0		1	30.00	50.00
H3916	024	0	1	04	01	H3916_024_0	5	2	Group 2	01	000000000000000011100000000000000000		2		2			2		1	1	2		30	30		1	30.00	50.00
H3916	025	0	1	04	01	H3916_025_0	6	1	Group 1	11	000000000000000100000000000000000100	000000000000000000001000	2		2			2		1	1	1	30	0	30	30	2		
H3916	025	0	1	04	01	H3916_025_0	6	8	Group 8	01	000000000000000000000000100000000000		2		2			2		2	1			0	50				
H3916	025	0	1	04	01	H3916_025_0	6	7	Group 7	01	000000000000000000000000000011000000		2		2			2		2	1			0	0				
H3916	025	0	1	04	01	H3916_025_0	6	6	Group 6	11	000000000000000000000000011000000000	000000010000000010000000	2		2			2		2	1			50	50				
H3916	025	0	1	04	01	H3916_025_0	6	9	Group 9	10		000000000000000000000001	1	500.00	2			2		2	1			0	0				
H3916	025	0	1	04	01	H3916_025_0	6	4	Group 4	11	011111111111111000011110000000001011	000000100000000000000110	2		2			2		2	1			30	30				
H3916	025	0	1	04	01	H3916_025_0	6	3	Group 3	01	000000000000000000000000000000100000		2		2			2		1	1	1	30	0	0	30	2		
H3916	025	0	1	04	01	H3916_025_0	6	2	Group 2	01	000000000000000011100000000000000000		2		2			2		1	1	1	30	30	30	30	2		
H3916	025	0	1	04	01	H3916_025_0	6	10	Group 10	01	000000000000000000000000000100010000		2		2			2		2	1			0	30				
H3916	025	0	1	04	01	H3916_025_0	6	5	Group 5	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	1			30	30				
H3916	801	0	1	04	01	H3916_801_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H3916	801	0	1	04	01	H3916_801_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H3916	801	0	1	04	01	H3916_801_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H3916	802	0	1	04	01	H3916_802_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H3916	802	0	1	04	01	H3916_802_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H3916	802	0	1	04	01	H3916_802_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H3916	804	0	1	04	01	H3916_804_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H3916	804	0	1	04	01	H3916_804_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
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H3921	001	0	1	04	01	H3921_001_0	7	3	Group 3	11	000000000000000011011000011001110010	000000000001000100000000	2		2			2		2	1			30	30				
H3921	001	0	1	04	01	H3921_001_0	7	4	Group 4	01	000000000000000100000000000000000000		2		1	13.00	13.00	2		2	1			30	30				
H3921	001	0	1	04	01	H3921_001_0	7	5	Group 5	01	000000000000000000100000000000000000		2		1	21.00	21.00	2		2	2								
H3921	001	0	1	04	01	H3921_001_0	7	6	Group 6	01	000010000000000000000000000000000000		2		1	75.00	75.00	2		2	2								
H3921	001	0	1	04	01	H3921_001_0	7	7	Group 7	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H3921	001	0	1	04	01	H3921_001_0	7	8	Group 8	01	000000000010010000000100000000000000		2		1	35.00	45.00	2		2	2								
H3921	001	0	1	04	01	H3921_001_0	7	9	Group 9	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H3921	001	0	1	04	01	H3921_001_0	7	1	Group 1	01	000000100000000000000000000000000000		2		1	20.00	20.00	2		2	2								
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H3921	001	0	1	04	01	H3921_001_0	7	11	Group 11	01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
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H3921	001	0	1	04	01	H3921_001_0	7	13	Group 13	01	000000000000100000000000000000000000		2		1	20.00	40.00	2		2	2								
H3921	001	0	1	04	01	H3921_001_0	7	14	Group 14	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H3921	001	0	1	04	01	H3921_001_0	7	2	Group 2	11	011100011101001000000000000000001101	000001000000000000001010	2		1	40.00	40.00	2		2	2								
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H3921	008	0	1	04	01	H3921_008_0	7	10	Group 10	11	000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2	2								
H3921	008	0	1	04	01	H3921_008_0	7	11	Group 11	01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H3921	008	0	1	04	01	H3921_008_0	7	12	Group 12	01	000001000000000000000000100000000000		2		2			2		2	1			50	50				
H3921	008	0	1	04	01	H3921_008_0	7	13	Group 13	01	000000000000100000000000000000000000		2		1	20.00	40.00	2		2	2								
H3921	008	0	1	04	01	H3921_008_0	7	14	Group 14	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H3921	008	0	1	04	01	H3921_008_0	7	9	Group 9	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H3921	008	0	1	04	01	H3921_008_0	7	3	Group 3	11	000000000000000011011000011001110010	000000000001000100000000	2		2			2		2	1			30	30				
H3921	008	0	1	04	01	H3921_008_0	7	4	Group 4	01	000000000000000100000000000000000000		2		1	13.00	13.00	2		2	1			30	30				
H3921	008	0	1	04	01	H3921_008_0	7	5	Group 5	01	000000000000000000100000000000000000		2		1	21.00	21.00	2		2	2								
H3921	008	0	1	04	01	H3921_008_0	7	6	Group 6	01	000010000000000000000000000000000000		2		1	75.00	75.00	2		2	2								
H3921	008	0	1	04	01	H3921_008_0	7	7	Group 7	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H3921	008	0	1	04	01	H3921_008_0	7	8	Group 8	01	000000000010010000000100000000000000		2		1	35.00	45.00	2		2	2								
H3921	008	0	1	04	01	H3921_008_0	7	2	Group 2	11	011100011101001000000000000000001101	000001000000000000001010	2		1	40.00	40.00	2		2	2								
H3923	013	0	1	04	01	H3923_013_0	10	1	Fitness/Health Class Benefit	10		000000000000000010000000	1	10.00	2			2		2	1			50	50				
H3923	013	0	1	04	01	H3923_013_0	10	2	Out Of Network	11	011111111111111111111111111111111111	000000100000000000001100	2		2			2		2	1			30	30				
H3923	017	0	1	04	01	H3923_017_0	9	1	Fitness/Health Class Benefit	10		000000000000000010000000	1	10.00	2			2		2	1			50	50				
H3923	017	0	1	04	01	H3923_017_0	9	2	Out of Network	11	011111111111111111111111111111111111	000000100000000000101111	2		2			2		2	1			20	20				
H3923	801	0	1	04	01	H3923_801_0	8	1	Out of Network	01	011111111111111111111111111111111111		2		2			2		2	1			50	50				
H3923	802	0	1	04	01	H3923_802_0	8	1	Out of Network	01	011111111111111111111111111111111111		2		2			2		2	1			50	50				
H3923	803	0	1	04	01	H3923_803_0	8	1	Out of Network	01	011111111111111111111111111111111111		2		2			2		2	1			50	50				
H3924	001	0	1	04	01	H3924_001_0	4	1	Primary Care Physician Services	11	000000100000000000000000000000000000	000000000000000100000000	2		1	20.00	20.00	2		2	2								
H3924	001	0	1	04	01	H3924_001_0	4	2	Specialty OON Services	11	000000010101000000000000000010001101	000001000001000000001010	2		1	35.00	35.00	2		2	2								
H3924	001	0	1	04	01	H3924_001_0	4	3	All Other Medicare Services	11	011111001010111111111111111101110000	000000000001000010000000	2		2			2		2	1			20	20				
H3924	001	0	1	04	01	H3924_001_0	4	4	Preventive Dental OON	10		000000000000000000100000	2		2			2		2	1			20	20				
H3924	001	0	1	04	01	H3924_001_0	4	5	Eyewear OON	11	000000000000000000000000000000000010	000000000000000000000100	1	200.00	1	0.00	0.00	2		2	2								
H3924	001	0	1	04	01	H3924_001_0	4	6	Hearing Aid OON	10		000000000000000000000001	1	800.00	1	0.00	0.00	2		2	2								
H3924	003	0	1	04	01	H3924_003_0	6	1	Primary Care Physician Services	11	000000100000000000000000000000000000	000000000000000100000000	2		1	20.00	20.00	2		2	2								
H3924	003	0	1	04	01	H3924_003_0	6	2	Specialty OON Services	11	000000010101000000000000000010001101	000001000001000000001010	2		1	35.00	35.00	2		2	2								
H3924	003	0	1	04	01	H3924_003_0	6	3	All Other Medicare Services	11	011111001010111111111111111101110000	000000000001000010000000	2		2			2		2	1			20	20				
H3924	003	0	1	04	01	H3924_003_0	6	4	Preventive Dental OON	10		000000000000000000100000	2		2			2		2	1			20	20				
H3924	003	0	1	04	01	H3924_003_0	6	5	Eyewear OON	11	000000000000000000000000000000000010	000000000000000000000100	1	200.00	1	0.00	0.00	2		2	2								
H3924	003	0	1	04	01	H3924_003_0	6	6	Hearing Aid OON	10		000000000000000000000001	1	800.00	1	0.00	0.00	2		2	2								
H3924	021	0	1	04	01	H3924_021_0	4	2	Specialty OON Services	11	000000010101000000000000000010001101	000001000001000000001010	2		1	35.00	35.00	2		2	2								
H3924	021	0	1	04	01	H3924_021_0	4	3	All Other Medicare Services	11	011111001010111111111111111101110000	000000000001000010000000	2		2			2		2	1			20	20				
H3924	021	0	1	04	01	H3924_021_0	4	4	Preventive Dental OON	10		000000000000000000100000	2		2			2		2	1			20	20				
H3924	021	0	1	04	01	H3924_021_0	4	5	Eyewear OON	11	000000000000000000000000000000000010	000000000000000000000100	1	200.00	1	0.00	0.00	2		2	2								
H3924	021	0	1	04	01	H3924_021_0	4	6	Hearing Aid OON	10		000000000000000000000001	1	800.00	1	0.00	0.00	2		2	2								
H3924	021	0	1	04	01	H3924_021_0	4	1	Primary Care Physician Services	11	000000100000000000000000000000000000	000000000000000100000000	2		1	20.00	20.00	2		2	2								
H3924	023	0	1	04	01	H3924_023_0	6	1	Primary Care Physician Services	11	000000100000000000000000000000000000	000000000000000100000000	2		1	20.00	20.00	2		2	2								
H3924	023	0	1	04	01	H3924_023_0	6	6	Hearing Aid OON	10		000000000000000000000001	1	800.00	1	0.00	0.00	2		2	2								
H3924	023	0	1	04	01	H3924_023_0	6	2	Specialty OON Services	11	000000010101000000000000000010001101	000001000001000000001010	2		1	35.00	35.00	2		2	2								
H3924	023	0	1	04	01	H3924_023_0	6	5	Eyewear OON	11	000000000000000000000000000000000010	000000000000000000000100	1	200.00	1	0.00	0.00	2		2	2								
H3924	023	0	1	04	01	H3924_023_0	6	4	Preventive Dental OON	10		000000000000000000100000	2		2			2		2	1			20	20				
H3924	023	0	1	04	01	H3924_023_0	6	3	All Other Medicare Services	11	011111001010111111111111111101110000	000000000001000010000000	2		2			2		2	1			20	20				
H3924	045	0	1	04	01	H3924_045_0	4	7	Hearing Aid	10		000000000000000000000001	1	800.00	1	0.00	0.00	2		2	2								
H3924	045	0	1	04	01	H3924_045_0	4	6	Eyewear	11	000000000000000000000000000000000010	000000000000000000000100	1	200.00	1	0.00	0.00	2		2	2								
H3924	045	0	1	04	01	H3924_045_0	4	5	Preventive Dental	10		000000000000000000100000	2		2			2		2	1			25	25				
H3924	045	0	1	04	01	H3924_045_0	4	1	Primary Care Physician Care Services	11	000000100000000000000000000000000000	000000000000000100000000	2		1	30.00	30.00	2		2	2								
H3924	045	0	1	04	01	H3924_045_0	4	2	Specialty OON Services	11	000000010101000000000000000010001101	000001000001000000001010	2		1	45.00	45.00	2		2	2								
H3924	045	0	1	04	01	H3924_045_0	4	3	Other OON Services	11	011101001000101111111011111101110000	000000000000000010000000	2		2			2		2	1			25	25				
H3924	045	0	1	04	01	H3924_045_0	4	4	Mental Health Services	01	000010000010010000000100000000000000		2		2			2		2	1			25	25				
H3924	046	0	1	04	01	H3924_046_0	6	3	Other OON Services	11	011101001000101111111011111101110000	000000000000000010000000	2		2			2		2	1			25	25				
H3924	046	0	1	04	01	H3924_046_0	6	4	Mental Health Services	01	000010000010010000000100000000000000		2		2			2		2	1			25	25				
H3924	046	0	1	04	01	H3924_046_0	6	1	Primary Care Physician Care Services	11	000000100000000000000000000000000000	000000000000000100000000	2		1	30.00	30.00	2		2	2								
H3924	046	0	1	04	01	H3924_046_0	6	2	Specialty OON Services	11	000000010101000000000000000010001101	000001000001000000001010	2		1	45.00	45.00	2		2	2								
H3924	046	0	1	04	01	H3924_046_0	6	5	Preventive Dental	10		000000000000000000100000	2		2			2		2	1			25	25				
H3924	046	0	1	04	01	H3924_046_0	6	6	Eyewear	11	000000000000000000000000000000000010	000000000000000000000100	1	200.00	1	0.00	0.00	2		2	2								
H3924	046	0	1	04	01	H3924_046_0	6	7	Hearing Aid	10		000000000000000000000001	1	800.00	1	0.00	0.00	2		2	2								
H3924	047	0	1	04	01	H3924_047_0	4	4	Mental Health Services	01	000010000010010000000100000000000000		2		2			2		2	1			25	25				
H3924	047	0	1	04	01	H3924_047_0	4	1	Primary Care Physician Care Services	11	000000100000000000000000000000000000	000000000000000100000000	2		1	30.00	30.00	2		2	2								
H3924	047	0	1	04	01	H3924_047_0	4	2	Specialty OON Services	11	000000010101000000000000000010001101	000001000001000000001010	2		1	45.00	45.00	2		2	2								
H3924	047	0	1	04	01	H3924_047_0	4	3	Other OON Services	11	011101001000101111111011111101110000	000000000000000010000000	2		2			2		2	1			25	25				
H3924	047	0	1	04	01	H3924_047_0	4	5	Preventive Dental	10		000000000000000000100000	2		2			2		2	1			25	25				
H3924	047	0	1	04	01	H3924_047_0	4	7	Hearing Aid	10		000000000000000000000001	1	800.00	1	0.00	0.00	2		2	2								
H3924	047	0	1	04	01	H3924_047_0	4	6	Eyewear	11	000000000000000000000000000000000010	000000000000000000000100	1	200.00	1	0.00	0.00	2		2	2								
H3924	048	0	1	04	01	H3924_048_0	6	1	Primary Care Physician Care Services	11	000000100000000000000000000000000000	000000000000000100000000	2		1	30.00	30.00	2		2	2								
H3924	048	0	1	04	01	H3924_048_0	6	2	Specialty OON Services	11	000000010101000000000000000010001101	000001000001000000001010	2		1	45.00	45.00	2		2	2								
H3924	048	0	1	04	01	H3924_048_0	6	3	Other OON Services	11	011101001000101111111011111101110000	000000000000000010000000	2		2			2		2	1			25	25				
H3924	048	0	1	04	01	H3924_048_0	6	4	Mental Health Services	01	000010000010010000000100000000000000		2		2			2		2	1			25	25				
H3924	048	0	1	04	01	H3924_048_0	6	7	Hearing Aid	10		000000000000000000000001	1	800.00	1	0.00	0.00	2		2	2								
H3924	048	0	1	04	01	H3924_048_0	6	6	Eyewear	11	000000000000000000000000000000000010	000000000000000000000100	1	200.00	1	0.00	0.00	2		2	2								
H3924	048	0	1	04	01	H3924_048_0	6	5	Preventive Dental	10		000000000000000000100000	2		2			2		2	1			25	25				
H3924	051	0	1	04	01	H3924_051_0	4	7	Hearing Aid	10		000000000000000000000001	1	800.00	1	0.00	0.00	2		2	2								
H3924	051	0	1	04	01	H3924_051_0	4	6	Eyewear	11	000000000000000000000000000000000010	000000000000000000000100	1	200.00	1	0.00	0.00	2		2	2								
H3924	051	0	1	04	01	H3924_051_0	4	5	Preventive Dental	10		000000000000000000100000	2		2			2		2	1			25	25				
H3924	051	0	1	04	01	H3924_051_0	4	2	Specialty OON Services	11	000000010101000000000000000010001101	000001000001000000001010	2		1	45.00	45.00	2		2	2								
H3924	051	0	1	04	01	H3924_051_0	4	1	Primary Care Physician Care Services	11	000000100000000000000000000000000000	000000000000000100000000	2		1	30.00	30.00	2		2	2								
H3924	051	0	1	04	01	H3924_051_0	4	3	Other OON Services	11	011101001000101111111011111101110000	000000000000000010000000	2		2			2		2	1			25	25				
H3924	051	0	1	04	01	H3924_051_0	4	4	Mental Health Services	01	000010000010010000000100000000000000		2		2			2		2	1			25	25				
H3924	052	0	1	04	01	H3924_052_0	6	6	Eyewear	11	000000000000000000000000000000000010	000000000000000000000100	1	200.00	1	0.00	0.00	2		2	2								
H3924	052	0	1	04	01	H3924_052_0	6	7	Hearing Aid	10		000000000000000000000001	1	800.00	1	0.00	0.00	2		2	2								
H3924	052	0	1	04	01	H3924_052_0	6	5	Preventive Dental	10		000000000000000000100000	2		2			2		2	1			25	25				
H3924	052	0	1	04	01	H3924_052_0	6	4	Mental Health Services	01	000010000010010000000100000000000000		2		2			2		2	1			25	25				
H3924	052	0	1	04	01	H3924_052_0	6	3	Other OON Services	11	011101001000101111111011111101110000	000000000000000010000000	2		2			2		2	1			25	25				
H3924	052	0	1	04	01	H3924_052_0	6	1	Primary Care Physician Care Services	11	000000100000000000000000000000000000	000000000000000100000000	2		1	30.00	30.00	2		2	2								
H3924	052	0	1	04	01	H3924_052_0	6	2	Specialty OON Services	11	000000010101000000000000000010001101	000001000001000000001010	2		1	45.00	45.00	2		2	2								
H3924	053	0	1	04	01	H3924_053_0	3	1	Primary Care Physician Services	11	000000100000000000000000000000000000	000000000000000100000000	2		1	20.00	20.00	2		2	2								
H3924	053	0	1	04	01	H3924_053_0	3	2	Specialty OON Services	11	000000010101000000000000000010001101	000001000001000000001010	2		1	35.00	35.00	2		2	2								
H3924	053	0	1	04	01	H3924_053_0	3	3	All Other Medicare Services	11	000011001010111111111111111101110000	000000000001000010000000	2		2			2		2	1			20	20				
H3924	053	0	1	04	01	H3924_053_0	3	4	Preventive Dental OON	10		000000000000000000100000	2		2			2		2	1			20	20				
H3924	053	0	1	04	01	H3924_053_0	3	5	Eyewear OON	11	000000000000000000000000000000000010	000000000000000000000100	1	200.00	1	0.00	0.00	2		2	2								
H3924	053	0	1	04	01	H3924_053_0	3	7	Cardiac and Pulmonary Therapy	01	011100000000000000000000000000000000		2		2			2		2	1			25	25				
H3924	053	0	1	04	01	H3924_053_0	3	6	Hearing Aid OON	10		000000000000000000000001	1	800.00	1	0.00	0.00	2		2	2								
H3924	054	0	1	04	01	H3924_054_0	5	5	Eyewear OON	11	000000000000000000000000000000000010	000000000000000000000100	1	200.00	1	0.00	0.00	2		2	2								
H3924	054	0	1	04	01	H3924_054_0	5	4	Preventive Dental OON	10		000000000000000000100000	2		2			2		2	1			20	20				
H3924	054	0	1	04	01	H3924_054_0	5	3	All Other Medicare Services	11	000011001010111111111111111101110000	000000000001000010000000	2		2			2		2	1			20	20				
H3924	054	0	1	04	01	H3924_054_0	5	2	Specialty OON Services	11	000000010101000000000000000010001101	000001000001000000001010	2		1	35.00	35.00	2		2	2								
H3924	054	0	1	04	01	H3924_054_0	5	1	Primary Care Physician Services	11	000000100000000000000000000000000000	000000000000000100000000	2		1	20.00	20.00	2		2	2								
H3924	054	0	1	04	01	H3924_054_0	5	6	Hearing Aid OON	10		000000000000000000000001	1	800.00	1	0.00	0.00	2		2	2								
H3924	054	0	1	04	01	H3924_054_0	5	7	Cardiac and Pulmonary Therapy	01	011100000000000000000000000000000000		2		2			2		2	1			25	25				
H3924	801	0	1	04	01	H3924_801_0	1	1	OON Medicare Covered Services	01	011101111101101111111011111111111111		2		2			2		2	1			20	20				
H3924	801	0	1	04	01	H3924_801_0	1	2	OON Mental Health/Substance Abuse	01	000010000010010000000100000000000000		2		2			2		2	1			35	35				
H3924	802	0	1	04	01	H3924_802_0	2	1	OON Medicare Covered Services	01	011101111101101111111011111111111111		2		2			2		2	1			20	20				
H3924	802	0	1	04	01	H3924_802_0	2	2	OON Mental Health/Substance Abuse	01	000010000010010000000100000000000000		2		2			2		2	1			35	35				
H4005	001	0	1	04	01	H4005_001_0	6	3	Group 3	11	000000000000000000000000000101000010	000000010000000010000101	2		1	0.00	0.00	2		2	2								
H4005	001	0	1	04	01	H4005_001_0	6	1	Group 1	11	000011100100110111111011111010010101	000000100000000000101000	2		2			2		2	1			20	20				
H4005	001	0	1	04	01	H4005_001_0	6	2	Group 2	11	011100011011001000000100000000101000	000011000001100000010000	2		2			2		2	1			25	25				
H4005	004	0	1	04	01	H4005_004_0	7	3	Group 3	11	000000000000000000000000000101000010	000000010000000010000101	2		1	0.00	0.00	2		2	2								
H4005	004	0	1	04	01	H4005_004_0	7	2	Group 2	11	011100011011001000000100000000101000	000000001001100000010000	2		2			2		2	1			25	25				
H4005	004	0	1	04	01	H4005_004_0	7	1	Group 1	11	000011100100110111111011111010010101	000000100000000000101000	2		2			2		2	1			20	20				
H4005	005	0	1	04	01	H4005_005_0	6	1	Group 1	11	000011100100110111111011111010010101	000000100000000000000000	2		2			2		2	1			20	20				
H4005	005	0	1	04	01	H4005_005_0	6	3	Group 3	11	000000000000000000000000000101000010	000000010000000010000000	2		1	0.00	0.00	2		2	2								
H4005	005	0	1	04	01	H4005_005_0	6	2	Group 2	11	011100011011001000000100000000101000	000000000001100000000000	2		2			2		2	1			25	25				
H4005	801	0	1	04	01	H4005_801_0	6	1	Group 1	11	011111111111111111111111111111111111	000000010001100010000000	2		2			2		2	1			20	20				
H4005	802	0	1	04	01	H4005_802_0	6	1	Group 1	11	011111111111111111111111111111111111	000000010001100010000000	2		2			2		2	1			20	20				
H4005	804	0	1	04	01	H4005_804_0	6	1	Group 1	11	011111111111111111111111111111111111	000000010001100010000000	2		2			2		2	1			20	20				
H4005	807	0	1	04	01	H4005_807_0	6	1	Group 1	11	011111111111111111111111111111111111	000000010001100010000000	2		2			2		2	1			20	20				
H4011	001	0	1	04	01	H4011_001_0	7	3		10		000000000000000000000001	2		2			2		2	2								
H4011	001	0	1	04	01	H4011_001_0	7	2		11	000000000010010000000100000000000010	000000000000000000000100	2		2			2		2	1			50	50				
H4011	001	0	1	04	01	H4011_001_0	7	1		11	011111111101101111111011111111111101	000011100000000010101010	2		2			2		2	1			20	20				
H4011	003	0	1	04	01	H4011_003_0	9	1		11	011111111101101111111011111111111101	000011100000000010111010	2		2			2		2	1			20	20				
H4011	003	0	1	04	01	H4011_003_0	9	3		11	000000000010010000000100000000000010	000000000000000000000100	2		2			2		2	1			50	50				
H4011	003	0	1	04	01	H4011_003_0	9	2		10		000000000000000000000001	2		2			2		2	2								
H4011	801	0	1	04	01	H4011_801_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H4011	801	0	1	04	01	H4011_801_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H4011	801	0	1	04	01	H4011_801_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H4011	803	0	1	04	01	H4011_803_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H4011	803	0	1	04	01	H4011_803_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H4011	803	0	1	04	01	H4011_803_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H4011	805	0	1	04	01	H4011_805_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H4011	805	0	1	04	01	H4011_805_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H4011	805	0	1	04	01	H4011_805_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H4011	807	0	1	04	01	H4011_807_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H4011	807	0	1	04	01	H4011_807_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H4011	807	0	1	04	01	H4011_807_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H4011	809	0	1	04	01	H4011_809_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H4011	809	0	1	04	01	H4011_809_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H4011	809	0	1	04	01	H4011_809_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H4011	811	0	1	04	01	H4011_811_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H4011	811	0	1	04	01	H4011_811_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H4011	811	0	1	04	01	H4011_811_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H4011	813	0	1	04	01	H4011_813_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H4011	813	0	1	04	01	H4011_813_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H4011	813	0	1	04	01	H4011_813_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H4011	815	0	1	04	01	H4011_815_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H4011	815	0	1	04	01	H4011_815_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H4011	815	0	1	04	01	H4011_815_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H4011	817	0	1	04	01	H4011_817_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H4011	817	0	1	04	01	H4011_817_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H4011	817	0	1	04	01	H4011_817_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H4011	820	0	1	04	01	H4011_820_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H4011	820	0	1	04	01	H4011_820_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H4011	820	0	1	04	01	H4011_820_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H4011	821	0	1	04	01	H4011_821_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H4011	821	0	1	04	01	H4011_821_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H4011	821	0	1	04	01	H4011_821_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H4011	822	0	1	04	01	H4011_822_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H4011	822	0	1	04	01	H4011_822_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H4011	822	0	1	04	01	H4011_822_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H4011	823	0	1	04	01	H4011_823_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H4011	823	0	1	04	01	H4011_823_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H4011	823	0	1	04	01	H4011_823_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H4011	824	0	1	04	01	H4011_824_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H4011	824	0	1	04	01	H4011_824_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H4011	824	0	1	04	01	H4011_824_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H4036	004	0	1	04	01	H4036_004_0	11	11	$30	01	000000010000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H4036	004	0	1	04	01	H4036_004_0	11	1	$0	11	011101000000000000000010000011101000	000000100000000010000000	2		1	0.00	0.00	2		2	2								
H4036	004	0	1	04	01	H4036_004_0	11	12	$0-$50	01	000000000000000000000000000000000100		2		1	0.00	50.00	2		2	2								
H4036	004	0	1	04	01	H4036_004_0	11	2	$50	01	000010001111011000000100000000000011		2		1	50.00	50.00	2		2	2								
H4036	004	0	1	04	01	H4036_004_0	11	3	$10	01	000000100000100000000000000000000000		2		1	10.00	10.00	2		2	2								
H4036	004	0	1	04	01	H4036_004_0	11	6	20%	01	000000000000000001000000000100010000		2		2			2		2	1			20	20				
H4036	004	0	1	04	01	H4036_004_0	11	5	$0-$20 / 35%	01	000000000000000100000000000000000000		2		1	0.00	20.00	2		2	1			35	35				
H4036	004	0	1	04	01	H4036_004_0	11	10	25%	01	000000000000000000001000000000000000		2		2			2		2	1			25	25				
H4036	004	0	1	04	01	H4036_004_0	11	9	$10-$50 / 25%	01	000000000000000000010000000000000000		2		1	10.00	50.00	2		2	1			25	25				
H4036	004	0	1	04	01	H4036_004_0	11	8	35%	01	000000000000000010100000000000000000		2		2			2		2	1			35	35				
H4036	004	0	1	04	01	H4036_004_0	11	7	30%	01	000000000000000000000000111000000000		2		2			2		2	1			30	30				
H4036	004	0	1	04	01	H4036_004_0	11	4	$150	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H4036	005	0	1	04	01	H4036_005_0	11	9	$10-$50 / 25%	01	000000000000000000010000000000000000		2		1	10.00	50.00	2		2	1			25	25				
H4036	005	0	1	04	01	H4036_005_0	11	6	20%	01	000000000000000001000000000100010000		2		2			2		2	1			20	20				
H4036	005	0	1	04	01	H4036_005_0	11	7	30%	01	000000000000000000000000111000000000		2		2			2		2	1			30	30				
H4036	005	0	1	04	01	H4036_005_0	11	8	$130-$180	01	000000000000000010100000000000000000		2		1	130.00	180.00	2		2	2								
H4036	005	0	1	04	01	H4036_005_0	11	3	$10	01	000000100000100000000000000000000000		2		1	10.00	10.00	2		2	2								
H4036	005	0	1	04	01	H4036_005_0	11	4	$150	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H4036	005	0	1	04	01	H4036_005_0	11	5	$0-$180	01	000000000000000100000000000000000000		2		1	0.00	180.00	2		2	2								
H4036	005	0	1	04	01	H4036_005_0	11	2	$50	01	000010001111011000000100000000000011		2		1	50.00	50.00	2		2	2								
H4036	005	0	1	04	01	H4036_005_0	11	12	$0-$50	01	000000000000000000000000000000000100		2		1	0.00	50.00	2		2	2								
H4036	005	0	1	04	01	H4036_005_0	11	11	$30	01	000000010000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H4036	005	0	1	04	01	H4036_005_0	11	10	25%	01	000000000000000000001000000000000000		2		2			2		2	1			25	25				
H4036	005	0	1	04	01	H4036_005_0	11	1	$0	11	011101000000000000000010000011101000	000000100000000010000000	2		1	0.00	0.00	2		2	2								
H4036	007	0	1	04	01	H4036_007_0	11	9	$20-$50 / 25%	01	000000000000000000010000000000000000		2		1	20.00	50.00	2		2	1			25	25				
H4036	007	0	1	04	01	H4036_007_0	11	8	$130-$180	01	000000000000000010100000000000000000		2		1	130.00	180.00	2		2	2								
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H4036	007	0	1	04	01	H4036_007_0	11	5	$0-$180	01	000000000000000100000000000000000000		2		1	0.00	180.00	2		2	2								
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H4209	001	0	1	04	01	H4209_001_0	9	4	Medicare-Covered Vision	01	000000000000000000000000000000000110		2		2			2		2	1			50	50				
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H4209	001	0	1	04	01	H4209_001_0	9	1	Thirty Percent Coinsurance Group	11	011111011111111111111110111111111001	000000100000000000000000	2		2			2		2	1			30	30				
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H4209	009	0	1	04	01	H4209_009_0	10	1	Thirty Percent Coinsurance Group	11	011111011111111111111110111111111001	000000100000000000000000	2		2			2		2	1			30	30				
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H4605	001	0	1	04	01	H4605_001_0	7	3	End-Stage Renal Disease	01	000000000000000000000000000100000000		2		2			2		2	1			10	10				
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H4605	001	0	1	04	01	H4605_001_0	7	11	$500 Preventive Dental	10		000000000000000000100000	2		2			2		2	1			20	20				
H4605	001	0	1	04	01	H4605_001_0	7	9	$0 to $225	01	000000000000000000010000000000000000		2		1	0.00	225.00	2		2	2								
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H4605	001	0	1	04	01	H4605_001_0	7	6	10% to 20%	01	000000000000000000000000000000010000		2		2			2		2	1			10	20				
H4605	001	0	1	04	01	H4605_001_0	7	7	$0 - no cost sharing	11	000010000000000100000010001011100010	000000100000000110000100	2		1	0.00	0.00	2		2	2								
H4605	001	0	1	04	01	H4605_001_0	7	8	$0 to $40	01	000000000000000000000000000000000100		2		1	0.00	40.00	2		2	2								
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H4605	002	0	1	04	01	H4605_002_0	9	9	$0 to $225	01	000000000000000000010000000000000000		2		1	0.00	225.00	2		2	2								
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H4605	002	0	1	04	01	H4605_002_0	9	7	$0 - no cost sharing	11	000010000000000100000010001011100010	000000100000000110000100	2		1	0.00	0.00	2		2	2								
H4605	002	0	1	04	01	H4605_002_0	9	6	10% to 20%	01	000000000000000000000000000000010000		2		2			2		2	1			10	20				
H4605	002	0	1	04	01	H4605_002_0	9	5	30% coinsurance	01	000000000000000010000000110000000000		2		2			2		2	1			30	30				
H4605	002	0	1	04	01	H4605_002_0	9	4	20%	01	000001000000000001100000000000000000		2		2			2		2	1			20	20				
H4605	002	0	1	04	01	H4605_002_0	9	10	$225	01	000000000000000000001000000000000000		2		1	225.00	225.00	2		2	2								
H4605	002	0	1	04	01	H4605_002_0	9	3	End-Stage Renal Disease	01	000000000000000000000000000100000000		2		2			2		2	1			10	10				
H4605	002	0	1	04	01	H4605_002_0	9	2	$200 copay	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H4605	002	0	1	04	01	H4605_002_0	9	12	$35	10		000000000000000000001000	2		1	35.00	35.00	2		2	2								
H4605	002	0	1	04	01	H4605_002_0	9	11	$500 Preventive Dental	10		000000000000000000100000	2		2			2		2	1			20	20				
H4605	004	0	1	04	01	H4605_004_0	10	1	$25	11	011100111111111000000100000000001001	000000000000000000001000	2		1	25.00	25.00	2		2	2								
H4605	004	0	1	04	01	H4605_004_0	10	10	$200	01	000000000000000000001000000000000000		2		1	200.00	200.00	2		2	2								
H4605	004	0	1	04	01	H4605_004_0	10	9	$0 to $200	01	000000000000000000010000000000000000		2		1	0.00	200.00	2		2	2								
H4605	004	0	1	04	01	H4605_004_0	10	8	$0 to $25	01	000000000000000000000000000000000100		2		1	0.00	25.00	2		2	2								
H4605	004	0	1	04	01	H4605_004_0	10	7	$0 - no cost sharing	11	000010000000000100000010001011100010	000000100000000110000100	2		1	0.00	0.00	2		2	2								
H4605	004	0	1	04	01	H4605_004_0	10	11	$500 Preventive Dental	10		000000000000000000100000	2		2			2		2	1			20	20				
H4605	004	0	1	04	01	H4605_004_0	10	12	30%	01	000000000000000010000000000000000000		2		2			2		2	1			30	30				
H4605	004	0	1	04	01	H4605_004_0	10	2	$200 copay	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H4605	004	0	1	04	01	H4605_004_0	10	3	End-Stage Renal Disease	01	000000000000000000000000000100000000		2		2			2		2	1			10	10				
H4605	004	0	1	04	01	H4605_004_0	10	4	10%	01	000001000000000000100000000000000000		2		2			2		2	1			10	10				
H4605	004	0	1	04	01	H4605_004_0	10	5	20% coinsurance	01	000000000000000001000000110000000000		2		2			2		2	1			20	20				
H4605	004	0	1	04	01	H4605_004_0	10	6	0% to 10%	01	000000000000000000000000000000010000		2		2			2		2	1			0	10				
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H4605	802	0	1	04	01	H4605_802_0	5	3	0% to 20%	01	000000000000000100000000000000000000		2		2			2		2	1			0	20				
H4605	802	0	1	04	01	H4605_802_0	5	4	20%	01	011110111101101011111101111101111101		2		2			2		2	1			20	20				
H4605	802	0	1	04	01	H4605_802_0	5	1	$0	01	000001000000000000000010000010000010		2		1	0.00	0.00	2		2	2								
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H4606	009	0	1	04	01	H4606_009_0	5	2		11	000000000000000000000011000000000010	000000100000000000001100	2		1	0.00	0.00	2		2	2								
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H4738	002	0	1	04	01	H4738_002_0	9	2	30	01	000000000000000000000000110000000000		2		2			2		2	1			30	30				
H4738	002	0	1	04	01	H4738_002_0	9	1	20% no	11	011111111111111000111111001111010000	000000100000000000000000	2		2			2		2	1			20	20				
H4738	002	0	1	04	01	H4738_002_0	9	6	hearing	10		000000000000000000000001	1	500.00	2			2		2	1			50	50				
H4738	002	0	1	04	01	H4738_002_0	9	5	eyewear	10		000000000000000000000100	1	100.00	2			2		2	1			50	50				
H4738	002	0	1	04	01	H4738_002_0	9	4	20 plus	01	000000000000000111000000000000100000		2		2			2		1	1	2		20	20		1	15.00	45.00
H4738	002	0	1	04	01	H4738_002_0	9	3	50	11	000000000000000000000000000000001111	000000000000000000001010	2		2			2		2	1			50	50				
H4754	001	0	1	04	01	H4754_001_0	12	11	Specialist copay	01	000000000100000000000000000000000000		2		1	40.00	40.00	2		2	2								
H4754	001	0	1	04	01	H4754_001_0	12	12	Alternative Care	10		000000001000000000000000	1	500.00	1	15.00	15.00	2		2	2								
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H4754	001	0	1	04	01	H4754_001_0	12	2	PCP copay	01	000000110000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H4754	001	0	1	04	01	H4754_001_0	12	3	Partial Hospitalization	01	000010000000000000000000000000000000		2		1	45.00	45.00	2		2	2								
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H4754	001	0	1	04	01	H4754_001_0	12	10	Eyewear	01	000000000000000000000000000000000010		2		2			2		2	2								
H4754	001	0	1	04	01	H4754_001_0	12	1	20% coinsurance	11	011100001011011000000110111011111101	000000000000000100001010	2		2			2		2	1			20	20				
H4754	001	0	1	04	01	H4754_001_0	12	9	Other health care professional	01	000000000000100000000000000000000000		2		1	25.00	40.00	2		2	2								
H4754	001	0	1	04	01	H4754_001_0	12	8	Ambulance	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H4754	001	0	1	04	01	H4754_001_0	12	5	ESRD	01	000000000000000000000000000100000000		2		1	15.00	15.00	2		2	2								
H4754	001	0	1	04	01	H4754_001_0	12	6	Outpatient Hospital and ASC	01	000000000000000000011000000000000000		2		1	300.00	300.00	2		2	2								
H4754	001	0	1	04	01	H4754_001_0	12	7	Physician copay	01	000000000000000111100000000000000000		2		2			2		1	1	2		20	20		1	25.00	40.00
H4754	002	0	1	04	01	H4754_002_0	9	1	20% coinsurance	11	011100001011011000000110111011111101	000000000000000100001010	2		2			2		2	1			20	20				
H4754	002	0	1	04	01	H4754_002_0	9	10	Eyewear	01	000000000000000000000000000000000010		2		2			2		2	2								
H4754	002	0	1	04	01	H4754_002_0	9	11	Routine Eye Wear	10		000000000000000000000100	1	100.00	2			2		2	2								
H4754	002	0	1	04	01	H4754_002_0	9	2	PCP copay	01	000000110000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H4754	002	0	1	04	01	H4754_002_0	9	3	Specialist copay	01	000010000100000000000000000000000000		2		1	30.00	30.00	2		2	2								
H4754	002	0	1	04	01	H4754_002_0	9	4	10% coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			10	10				
H4754	002	0	1	04	01	H4754_002_0	9	5	ESRD	01	000000000000000000000000000100000000		2		1	10.00	10.00	2		2	2								
H4754	002	0	1	04	01	H4754_002_0	9	6	Outpatient Hospital and ASC	01	000000000000000000011000000000000000		2		1	175.00	175.00	2		2	2								
H4754	002	0	1	04	01	H4754_002_0	9	7	Physician copay	01	000000000000000111100000000000000000		2		2			2		1	1	2		20	20		1	20.00	30.00
H4754	002	0	1	04	01	H4754_002_0	9	8	Ambulance	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H4754	002	0	1	04	01	H4754_002_0	9	9	Other health care professional	01	000000000000100000000000000000000000		2		1	20.00	30.00	2		2	2								
H4754	004	0	1	04	01	H4754_004_0	9	12	Routine Eye Wear	10		000000000000000000000100	1	100.00	2			2		2	2								
H4754	004	0	1	04	01	H4754_004_0	9	2	PCP copay	01	000000100000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H4754	004	0	1	04	01	H4754_004_0	9	3	Specialist copay	01	000010010100000000000000000000000000		2		1	25.00	25.00	2		2	2								
H4754	004	0	1	04	01	H4754_004_0	9	4	$0 copay	01	000001000000000000000000000000000000		2		2			2		2	2								
H4754	004	0	1	04	01	H4754_004_0	9	5	ESRD	01	000000000000000000000000000100000000		2		1	10.00	10.00	2		2	2								
H4754	004	0	1	04	01	H4754_004_0	9	6	Outpatient Hospital and ASC	01	000000000000000000011000000000000000		2		1	300.00	300.00	2		2	2								
H4754	004	0	1	04	01	H4754_004_0	9	7	Physician copay	01	000000000000000011100000000000000000		2		2			2		1	1	2		20	20		1	20.00	25.00
H4754	004	0	1	04	01	H4754_004_0	9	8	Ambulance	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H4754	004	0	1	04	01	H4754_004_0	9	9	Other health care professional	01	000000000000100000000000000000000000		2		1	20.00	25.00	2		2	2								
H4754	004	0	1	04	01	H4754_004_0	9	1	20% coinsurance	11	011100001011011000000110111011111101	000000000000000100001010	2		2			2		2	1			20	20				
H4754	004	0	1	04	01	H4754_004_0	9	10	Eyewear	11	000000000000000000000000000000000010	000000000000000000000100	2		2			2		2	2								
H4754	004	0	1	04	01	H4754_004_0	9	11	Laboratory services	01	000000000000000100000000000000000000		2		2			2		1	2	2					1	20.00	25.00
H4754	005	0	1	04	01	H4754_005_0	12	1	20% coinsurance	11	011100001011011000000110111011111101	000000000000000100001010	2		2			2		2	1			20	20				
H4754	005	0	1	04	01	H4754_005_0	12	10	Eyewear	11	000000000000000000000000000000000010	000000000000000000000100	2		2			2		2	2								
H4754	005	0	1	04	01	H4754_005_0	12	11	Laboratory services	01	000000000000000100000000000000000000		2		2			2		1	2	2					1	20.00	25.00
H4754	005	0	1	04	01	H4754_005_0	12	12	Routine Eye Wear	10		000000000000000000000100	1	100.00	2			2		2	2								
H4754	005	0	1	04	01	H4754_005_0	12	2	PCP copay	01	000000100000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H4754	005	0	1	04	01	H4754_005_0	12	9	Other health care professional	01	000000000000100000000000000000000000		2		1	20.00	25.00	2		2	2								
H4754	005	0	1	04	01	H4754_005_0	12	4	$0 copay	01	000001000000000000000000000000000000		2		2			2		2	2								
H4754	005	0	1	04	01	H4754_005_0	12	5	ESRD	01	000000000000000000000000000100000000		2		1	10.00	10.00	2		2	2								
H4754	005	0	1	04	01	H4754_005_0	12	6	Outpatient Hospital and ASC	01	000000000000000000011000000000000000		2		1	300.00	300.00	2		2	2								
H4754	005	0	1	04	01	H4754_005_0	12	7	Physician copay	01	000000000000000011100000000000000000		2		2			2		1	1	2		20	20		1	20.00	25.00
H4754	005	0	1	04	01	H4754_005_0	12	8	Ambulance	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H4754	005	0	1	04	01	H4754_005_0	12	3	Specialist copay	01	000010010100000000000000000000000000		2		1	25.00	25.00	2		2	2								
H4754	006	0	1	04	01	H4754_006_0	11	4	10% coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			10	10				
H4754	006	0	1	04	01	H4754_006_0	11	5	ESRD	01	000000000000000000000000000100000000		2		1	10.00	10.00	2		2	2								
H4754	006	0	1	04	01	H4754_006_0	11	6	Outpatient Hospital and ASC	01	000000000000000000011000000000000000		2		1	175.00	175.00	2		2	2								
H4754	006	0	1	04	01	H4754_006_0	11	7	Physician copay	01	000000000000000111100000000000000000		2		2			2		1	1	2		20	20		1	20.00	30.00
H4754	006	0	1	04	01	H4754_006_0	11	8	Ambulance	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H4754	006	0	1	04	01	H4754_006_0	11	9	Other health care professional	01	000000000000100000000000000000000000		2		1	20.00	30.00	2		2	2								
H4754	006	0	1	04	01	H4754_006_0	11	1	20% coinsurance	11	011100001011011000000110111011111101	000000000000000100001010	2		2			2		2	1			20	20				
H4754	006	0	1	04	01	H4754_006_0	11	10	Eyewear	01	000000000000000000000000000000000010		2		2			2		2	2								
H4754	006	0	1	04	01	H4754_006_0	11	11	Routine Eye Wear	10		000000000000000000000100	1	100.00	2			2		2	2								
H4754	006	0	1	04	01	H4754_006_0	11	2	PCP copay	01	000000110000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H4754	006	0	1	04	01	H4754_006_0	11	3	Specialist copay	01	000010000100000000000000000000000000		2		1	30.00	30.00	2		2	2								
H4754	007	0	1	04	01	H4754_007_0	8	9	Other health care professional	01	000000000000100000000000000000000000		2		1	25.00	40.00	2		2	2								
H4754	007	0	1	04	01	H4754_007_0	8	8	Ambulance	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H4754	007	0	1	04	01	H4754_007_0	8	7	Physician copay	01	000000000000000111100000000000000000		2		2			2		1	1	2		20	20		1	25.00	40.00
H4754	007	0	1	04	01	H4754_007_0	8	6	Outpatient Hospital and ASC	01	000000000000000000011000000000000000		2		1	300.00	300.00	2		2	2								
H4754	007	0	1	04	01	H4754_007_0	8	1	20% coinsurance	11	011100011011011000000110111011111101	000000000000000100001010	2		2			2		2	1			20	20				
H4754	007	0	1	04	01	H4754_007_0	8	4	10% coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			10	10				
H4754	007	0	1	04	01	H4754_007_0	8	3	Specialist copay	01	000010000100000000000000000000000000		2		1	40.00	40.00	2		2	2								
H4754	007	0	1	04	01	H4754_007_0	8	2	PCP copay	01	000000100000000000000000000100000000		2		1	25.00	25.00	2		2	2								
H4754	007	0	1	04	01	H4754_007_0	8	10	Routine Eye Wear	10		000000000000000000000100	1	100.00	2			2		2	2								
H4754	007	0	1	04	01	H4754_007_0	8	5	Eyewear	01	000000000000000000000000000000000010		2		2			2		2	2								
H4754	008	0	1	04	01	H4754_008_0	10	8	Ambulance	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H4754	008	0	1	04	01	H4754_008_0	10	9	Other health care professional	01	000000000000100000000000000000000000		2		1	25.00	40.00	2		2	2								
H4754	008	0	1	04	01	H4754_008_0	10	7	Physician copay	01	000000000000000111100000000000000000		2		2			2		1	1	2		20	20		1	25.00	40.00
H4754	008	0	1	04	01	H4754_008_0	10	6	Outpatient Hospital and ASC	01	000000000000000000011000000000000000		2		1	300.00	300.00	2		2	2								
H4754	008	0	1	04	01	H4754_008_0	10	5	Eyewear	01	000000000000000000000000000000000010		2		2			2		2	2								
H4754	008	0	1	04	01	H4754_008_0	10	4	10% coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			10	10				
H4754	008	0	1	04	01	H4754_008_0	10	3	Specialist copay	01	000010000100000000000000000000000000		2		1	40.00	40.00	2		2	2								
H4754	008	0	1	04	01	H4754_008_0	10	2	PCP copay	01	000000100000000000000000000100000000		2		1	25.00	25.00	2		2	2								
H4754	008	0	1	04	01	H4754_008_0	10	10	Routine Eye Wear	10		000000000000000000000100	1	100.00	2			2		2	2								
H4754	008	0	1	04	01	H4754_008_0	10	1	20% coinsurance	11	011100011011011000000110111011111101	000000000000000100001010	2		2			2		2	1			20	20				
H4754	009	0	1	04	01	H4754_009_0	9	6	Outpatient Hospital and ASC	01	000000000000000000011000000000000000		2		1	300.00	300.00	2		2	2								
H4754	009	0	1	04	01	H4754_009_0	9	5	Eyewear	01	000000000000000000000000000000000010		2		2			2		2	2								
H4754	009	0	1	04	01	H4754_009_0	9	4	10% coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			10	10				
H4754	009	0	1	04	01	H4754_009_0	9	3	Specialist copay	01	000010000100000000000000000000000000		2		1	40.00	40.00	2		2	2								
H4754	009	0	1	04	01	H4754_009_0	9	7	Physician copay	01	000000000000000111100000000000000000		2		2			2		1	1	2		20	20		1	25.00	40.00
H4754	009	0	1	04	01	H4754_009_0	9	10	Routine Eye Wear	10		000000000000000000000100	1	100.00	2			2		2	2								
H4754	009	0	1	04	01	H4754_009_0	9	1	20% coinsurance	11	011100011011011000000110111011111101	000000000000000100001010	2		2			2		2	1			20	20				
H4754	009	0	1	04	01	H4754_009_0	9	8	Ambulance	01	000000000000000000000001000000000000		2		1	155.00	155.00	2		2	2								
H4754	009	0	1	04	01	H4754_009_0	9	9	Other health care professional	01	000000000000100000000000000000000000		2		1	25.00	40.00	2		2	2								
H4754	009	0	1	04	01	H4754_009_0	9	2	PCP copay	01	000000100000000000000000000100000000		2		1	25.00	25.00	2		2	2								
H4754	010	0	1	04	01	H4754_010_0	10	1	20% coinsurance	11	011100011011011000000110111011111101	000000000000000100001010	2		2			2		2	1			20	20				
H4754	010	0	1	04	01	H4754_010_0	10	10	Routine Eye Wear	10		000000000000000000000100	1	100.00	2			2		2	2								
H4754	010	0	1	04	01	H4754_010_0	10	2	PCP copay	01	000000100000000000000000000100000000		2		1	25.00	25.00	2		2	2								
H4754	010	0	1	04	01	H4754_010_0	10	3	Specialist copay	01	000010000100000000000000000000000000		2		1	40.00	40.00	2		2	2								
H4754	010	0	1	04	01	H4754_010_0	10	4	10% coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			10	10				
H4754	010	0	1	04	01	H4754_010_0	10	5	Eyewear	01	000000000000000000000000000000000010		2		2			2		2	2								
H4754	010	0	1	04	01	H4754_010_0	10	6	Outpatient Hospital and ASC	01	000000000000000000011000000000000000		2		1	300.00	300.00	2		2	2								
H4754	010	0	1	04	01	H4754_010_0	10	7	Physician copay	01	000000000000000111100000000000000000		2		2			2		1	1	2		20	20		1	25.00	40.00
H4754	010	0	1	04	01	H4754_010_0	10	8	Ambulance	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H4754	010	0	1	04	01	H4754_010_0	10	9	Other health care professional	01	000000000000100000000000000000000000		2		1	25.00	40.00	2		2	2								
H4754	011	0	1	04	01	H4754_011_0	9	10	Routine Eye Wear	10		000000000000000000000100	1	100.00	2			2		2	2								
H4754	011	0	1	04	01	H4754_011_0	9	1	20% coinsurance	11	011100011011011000000110111011111101	000000000000000100001010	2		2			2		2	1			20	20				
H4754	011	0	1	04	01	H4754_011_0	9	2	PCP copay	01	000000100000000000000000000100000000		2		1	25.00	25.00	2		2	2								
H4754	011	0	1	04	01	H4754_011_0	9	3	Specialist copay	01	000010000100000000000000000000000000		2		1	40.00	40.00	2		2	2								
H4754	011	0	1	04	01	H4754_011_0	9	4	10% coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			10	10				
H4754	011	0	1	04	01	H4754_011_0	9	5	Eyewear	01	000000000000000000000000000000000010		2		2			2		2	2								
H4754	011	0	1	04	01	H4754_011_0	9	6	Outpatient Hospital and ASC	01	000000000000000000011000000000000000		2		1	300.00	300.00	2		2	2								
H4754	011	0	1	04	01	H4754_011_0	9	7	Physician copay	01	000000000000000111100000000000000000		2		2			2		1	1	2		20	20		1	25.00	40.00
H4754	011	0	1	04	01	H4754_011_0	9	8	Ambulance	01	000000000000000000000001000000000000		2		1	155.00	155.00	2		2	2								
H4754	011	0	1	04	01	H4754_011_0	9	9	Other health care professional	01	000000000000100000000000000000000000		2		1	25.00	40.00	2		2	2								
H4754	012	0	1	04	01	H4754_012_0	10	8	Ambulance	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H4754	012	0	1	04	01	H4754_012_0	10	7	Physician copay	01	000000000000000111100000000000000000		2		2			2		1	1	2		20	20		1	25.00	40.00
H4754	012	0	1	04	01	H4754_012_0	10	6	Outpatient Hospital and ASC	01	000000000000000000011000000000000000		2		1	300.00	300.00	2		2	2								
H4754	012	0	1	04	01	H4754_012_0	10	5	Eyewear	01	000000000000000000000000000000000010		2		2			2		2	2								
H4754	012	0	1	04	01	H4754_012_0	10	9	Other health care professional	01	000000000000100000000000000000000000		2		1	25.00	40.00	2		2	2								
H4754	012	0	1	04	01	H4754_012_0	10	3	Specialist copay	01	000010000100000000000000000000000000		2		1	40.00	40.00	2		2	2								
H4754	012	0	1	04	01	H4754_012_0	10	2	PCP copay	01	000000100000000000000000000100000000		2		1	25.00	25.00	2		2	2								
H4754	012	0	1	04	01	H4754_012_0	10	10	Routine Eye Wear	10		000000000000000000000100	1	100.00	2			2		2	2								
H4754	012	0	1	04	01	H4754_012_0	10	1	20% coinsurance	11	011100011011011000000110111011111101	000000000000000100001010	2		2			2		2	1			20	20				
H4754	012	0	1	04	01	H4754_012_0	10	4	10% coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			10	10				
H4754	801	0	1	04	01	H4754_801_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
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H4754	802	0	1	04	01	H4754_802_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
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H4785	001	0	1	09	04	H4785_001_0	6	1		01	000010000000000000001001111100010000		2		2			2		2	1			20	20				
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H4785	001	0	1	09	04	H4785_001_0	6	11		01	000000000000000000100000000000000000		2		1	15.00	40.00	2		2	1			20	25				
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H4875	016	1	1	04	01	H4875_016_1	9	5	$0 Copayment	11	000001000000000000000000000000000000	000000100001000000000000	2		1	0.00	0.00	2		2	2								
H4875	016	1	1	04	01	H4875_016_1	9	4	$100 Copayment	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
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H4875	016	2	1	04	01	H4875_016_2	8	5	$0 Copayment	11	000001000000000000000000000000000000	000000100001000000000000	2		1	0.00	0.00	2		2	2								
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H4875	016	3	1	04	01	H4875_016_3	8	5	$0 Copayment	11	000001000000000000000000000000000000	000000100001000000000000	2		1	0.00	0.00	2		2	2								
H4875	016	3	1	04	01	H4875_016_3	8	1	40% Coinsurance	01	000010000000000000000000000000000000		2		2			2		2	1			40	40				
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H4875	016	3	1	04	01	H4875_016_3	8	4	$100 Copayment	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
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H5096	003	0	1	04	01	H5096_003_0	5	10	30% Hospital Out Pt GP	11	000001000000000000010010111001100000	000000100000000010000000	2		2			2		2	1			30	30				
H5096	003	0	1	04	01	H5096_003_0	5	1	$0 GP	01	000000000000000000000000000010000000		2		2			2		2	2								
H5096	003	0	1	04	01	H5096_003_0	5	9	20% DME GP	01	000000000000000000000000000100010000		2		2			2		2	1			20	20				
H5096	003	0	1	04	01	H5096_003_0	5	8	10% ASC gp	01	000000000000000000001000000000000000		2		2			2		2	1			10	10				
H5096	003	0	1	04	01	H5096_003_0	5	7	$60 Radio Therapy GP	01	000000000000000001000000000000000000		2		1	60.00	60.00	2		2	2								
H5096	003	0	1	04	01	H5096_003_0	5	12	Diag Radiology $0 - $50 or 10%	01	000000000000000110000000000000000000		2		1	0.00	50.00	2		2	1			10	10				
H5096	003	0	1	04	01	H5096_003_0	5	5	$40  Mental OPT GP	01	000010000010010000000100000000000000		2		1	40.00	40.00	2		2	2								
H5096	003	0	1	04	01	H5096_003_0	5	4	$30 PCP GP	01	000000100000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H5096	003	0	1	04	01	H5096_003_0	5	3	$20 Chiro	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H5096	003	0	1	04	01	H5096_003_0	5	2	$5 Basic X-Ray	01	000000000000000000100000000000000000		2		1	5.00	5.00	2		2	2								
H5096	003	0	1	04	01	H5096_003_0	5	14	$10 for Eye Wear	01	000000000000000000000000000000000010		2		1	10.00	10.00	2		2	2								
H5096	003	0	1	04	01	H5096_003_0	5	13	$0-$50	01	000000000000000000000000000000000100		2		1	0.00	50.00	2		2	2								
H5096	003	0	1	04	01	H5096_003_0	5	6	$50 Other Professional GP	01	011100001101101000000000000000001001		2		1	50.00	50.00	2		2	2								
H5106	013	0	1	04	01	H5106_013_0	7	8	Group 8	01	000000000000000000000000100000000000		2		2			2		2	1			0	50				
H5106	013	0	1	04	01	H5106_013_0	7	7	Group 7	01	000000000000000000000000000011000000		2		2			2		2	1			0	0				
H5106	013	0	1	04	01	H5106_013_0	7	6	Group 6	11	000000000000000000000000011000000000	000000010000000000000000	2		2			2		2	1			50	50				
H5106	013	0	1	04	01	H5106_013_0	7	5	Group 5	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	1			30	30				
H5106	013	0	1	04	01	H5106_013_0	7	4	Group 4	11	011111011011111000011110000000001011	000000100000000000000110	2		2			2		2	1			30	30				
H5106	013	0	1	04	01	H5106_013_0	7	3	Group 3	01	000000000000000000000000000000100000		2		2			2		1	1	2		0	0		1	30.00	50.00
H5106	013	0	1	04	01	H5106_013_0	7	9	Group 9	10		000000000000000010000000	2		2			1	500.00	2	1			50	50				
H5106	013	0	1	04	01	H5106_013_0	7	13	Group 13	01	000000000000000000000000000100010000		2		2			2		2	1			0	30				
H5106	013	0	1	04	01	H5106_013_0	7	12	Group 12	01	000000000100000000000000000000000000		2		1	50.00	50.00	2		2	2								
H5106	013	0	1	04	01	H5106_013_0	7	11	Group 11	01	000000100000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H5106	013	0	1	04	01	H5106_013_0	7	10	Group 10	10		000000000000000000000001	1	500.00	2			2		2	1			0	0				
H5106	013	0	1	04	01	H5106_013_0	7	1	Group 1	11	000000000000000100000000000000000100	000000000000000000001000	2		2			2		1	1	2		0	30		1	30.00	50.00
H5106	013	0	1	04	01	H5106_013_0	7	2	Group 2	01	000000000000000011100000000000000000		2		2			2		1	1	2		30	30		1	30.00	50.00
H5106	014	0	1	04	01	H5106_014_0	8	9	Group 9	10		000000000000000010000000	2		2			1	500.00	2	1			50	50				
H5106	014	0	1	04	01	H5106_014_0	8	8	Group 8	01	000000000000000000000000100000000000		2		2			2		2	1			0	50				
H5106	014	0	1	04	01	H5106_014_0	8	7	Group 7	01	000000000000000000000000000011000000		2		2			2		2	1			0	0				
H5106	014	0	1	04	01	H5106_014_0	8	6	Group 6	11	000000000000000000000000011000000000	000000010000000000100000	2		2			2		2	1			50	50				
H5106	014	0	1	04	01	H5106_014_0	8	5	Group 5	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	1			30	30				
H5106	014	0	1	04	01	H5106_014_0	8	4	Group 4	11	011111011011111000011110000000000011	000011100000000000000110	2		2			2		2	1			30	30				
H5106	014	0	1	04	01	H5106_014_0	8	3	Group 3	01	000000000000000000000000000000100000		2		2			2		1	1	2		0	0		1	30.00	45.00
H5106	014	0	1	04	01	H5106_014_0	8	2	Group 2	01	000000000000000011100000000000000000		2		2			2		1	1	2		30	30		1	30.00	45.00
H5106	014	0	1	04	01	H5106_014_0	8	14	Group 14	11	000000000000000000000000000000001000	000000000000000000010000	2		2			2		2	1			30	50				
H5106	014	0	1	04	01	H5106_014_0	8	13	Group13	01	000000000000000000000000000100010000		2		2			2		2	1			0	30				
H5106	014	0	1	04	01	H5106_014_0	8	12	Group 12	01	000000000100000000000000000000000000		2		1	45.00	45.00	2		2	2								
H5106	014	0	1	04	01	H5106_014_0	8	11	Group 11	01	000000100000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H5106	014	0	1	04	01	H5106_014_0	8	1	Group 1	11	000000000000000100000000000000000100	000000000000000000001000	2		2			2		1	1	2		0	30		1	30.00	45.00
H5106	014	0	1	04	01	H5106_014_0	8	10	Group 10	10		000000000000000000000001	1	500.00	2			2		2	1			0	0				
H5106	015	0	1	04	01	H5106_015_0	7	1	Group 1	11	000000000000000100000000000000000100	000000000000000000001000	2		2			2		1	1	2		0	30		1	30.00	50.00
H5106	015	0	1	04	01	H5106_015_0	7	10	Group 10	10		000000000000000000000001	1	500.00	2			2		2	1			0	0				
H5106	015	0	1	04	01	H5106_015_0	7	11	Group 11	01	000000100000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H5106	015	0	1	04	01	H5106_015_0	7	12	Group 12	01	000000000100000000000000000000000000		2		1	50.00	50.00	2		2	2								
H5106	015	0	1	04	01	H5106_015_0	7	13	Group 13	01	000000000000000000000000000100010000		2		2			2		2	1			0	30				
H5106	015	0	1	04	01	H5106_015_0	7	2	Group 2	01	000000000000000011100000000000000000		2		2			2		1	1	2		30	30		1	30.00	50.00
H5106	015	0	1	04	01	H5106_015_0	7	9	Group 9	10		000000000000000010000000	2		2			1	500.00	2	1			50	50				
H5106	015	0	1	04	01	H5106_015_0	7	4	Group 4	11	011111011011111000011110000000001011	000000100000000000000110	2		2			2		2	1			30	30				
H5106	015	0	1	04	01	H5106_015_0	7	5	Group 5	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	1			30	30				
H5106	015	0	1	04	01	H5106_015_0	7	6	Group 6	11	000000000000000000000000011000000000	000000010000000000000000	2		2			2		2	1			50	50				
H5106	015	0	1	04	01	H5106_015_0	7	7	Group 7	01	000000000000000000000000000011000000		2		2			2		2	1			0	0				
H5106	015	0	1	04	01	H5106_015_0	7	8	Group 8	01	000000000000000000000000100000000000		2		2			2		2	1			0	50				
H5106	015	0	1	04	01	H5106_015_0	7	3	Group 3	01	000000000000000000000000000000100000		2		2			2		1	1	2		0	0		1	30.00	50.00
H5106	016	0	1	04	01	H5106_016_0	8	8	Group 8	01	000000000000000000000000100000000000		2		2			2		2	1			0	50				
H5106	016	0	1	04	01	H5106_016_0	8	9	Group 9	10		000000000000000010000000	2		2			1	500.00	2	1			50	50				
H5106	016	0	1	04	01	H5106_016_0	8	1	Group 1	11	000000000000000100000000000000000100	000000000000000000001000	2		2			2		1	1	2		0	30		1	30.00	45.00
H5106	016	0	1	04	01	H5106_016_0	8	10	Group 10	10		000000000000000000000001	1	500.00	2			2		2	1			0	0				
H5106	016	0	1	04	01	H5106_016_0	8	11	Group 11	01	000000100000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H5106	016	0	1	04	01	H5106_016_0	8	12	Group 12	01	000000000100000000000000000000000000		2		1	45.00	45.00	2		2	2								
H5106	016	0	1	04	01	H5106_016_0	8	13	Group13	01	000000000000000000000000000100010000		2		2			2		2	1			0	30				
H5106	016	0	1	04	01	H5106_016_0	8	14	Group 14	11	000000000000000000000000000000001000	000000000000000000010000	2		2			2		2	1			30	50				
H5106	016	0	1	04	01	H5106_016_0	8	2	Group 2	01	000000000000000011100000000000000000		2		2			2		1	1	2		30	30		1	30.00	45.00
H5106	016	0	1	04	01	H5106_016_0	8	3	Group 3	01	000000000000000000000000000000100000		2		2			2		1	1	2		0	0		1	30.00	45.00
H5106	016	0	1	04	01	H5106_016_0	8	4	Group 4	11	011111011011111000011110000000000011	000011100000000000000110	2		2			2		2	1			30	30				
H5106	016	0	1	04	01	H5106_016_0	8	5	Group 5	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	1			30	30				
H5106	016	0	1	04	01	H5106_016_0	8	6	Group 6	11	000000000000000000000000011000000000	000000010000000000100000	2		2			2		2	1			50	50				
H5106	016	0	1	04	01	H5106_016_0	8	7	Group 7	01	000000000000000000000000000011000000		2		2			2		2	1			0	0				
H5106	017	0	1	04	01	H5106_017_0	5	6	Group 6	11	000000000000000000000000011000000000	000000010000000000000000	2		2			2		2	1			50	50				
H5106	017	0	1	04	01	H5106_017_0	5	5	Group 5	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	1			30	30				
H5106	017	0	1	04	01	H5106_017_0	5	4	Group 4	11	011111011011111000011110000000001011	000000100000000000000110	2		2			2		2	1			30	30				
H5106	017	0	1	04	01	H5106_017_0	5	3	Group 3	01	000000000000000000000000000000100000		2		2			2		1	1	2		0	0		1	30.00	50.00
H5106	017	0	1	04	01	H5106_017_0	5	2	Group 2	01	000000000000000011100000000000000000		2		2			2		1	1	2		30	30		1	30.00	50.00
H5106	017	0	1	04	01	H5106_017_0	5	13	Group 13	01	000000000000000000000000000100010000		2		2			2		2	1			0	30				
H5106	017	0	1	04	01	H5106_017_0	5	12	Group 12	01	000000000100000000000000000000000000		2		1	50.00	50.00	2		2	2								
H5106	017	0	1	04	01	H5106_017_0	5	8	Group 8	01	000000000000000000000000100000000000		2		2			2		2	1			0	50				
H5106	017	0	1	04	01	H5106_017_0	5	7	Group 7	01	000000000000000000000000000011000000		2		2			2		2	1			0	0				
H5106	017	0	1	04	01	H5106_017_0	5	1	Group 1	11	000000000000000100000000000000000100	000000000000000000001000	2		2			2		1	1	2		0	30		1	30.00	50.00
H5106	017	0	1	04	01	H5106_017_0	5	10	Group 10	10		000000000000000000000001	1	500.00	2			2		2	1			0	0				
H5106	017	0	1	04	01	H5106_017_0	5	11	Group 11	01	000000100000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H5106	017	0	1	04	01	H5106_017_0	5	9	Group 9	10		000000000000000010000000	2		2			1	500.00	2	1			50	50				
H5106	018	0	1	04	01	H5106_018_0	5	2	Group 2	01	000000000000000011100000000000000000		2		2			2		1	1	2		30	30		1	30.00	50.00
H5106	018	0	1	04	01	H5106_018_0	5	3	Group 3	01	000000000000000000000000000000100000		2		2			2		1	1	2		0	0		1	30.00	50.00
H5106	018	0	1	04	01	H5106_018_0	5	4	Group 4	11	011111011011111000011110000000001011	000000100000000000000110	2		2			2		2	1			30	30				
H5106	018	0	1	04	01	H5106_018_0	5	5	Group 5	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	1			30	30				
H5106	018	0	1	04	01	H5106_018_0	5	6	Group 6	11	000000000000000000000000011000000000	000000010000000000000000	2		2			2		2	1			50	50				
H5106	018	0	1	04	01	H5106_018_0	5	8	Group 8	01	000000000000000000000000100000000000		2		2			2		2	1			0	50				
H5106	018	0	1	04	01	H5106_018_0	5	7	Group 7	01	000000000000000000000000000011000000		2		2			2		2	1			0	0				
H5106	018	0	1	04	01	H5106_018_0	5	1	Group 1	11	000000000000000100000000000000000100	000000000000000000001000	2		2			2		1	1	2		0	30		1	30.00	50.00
H5106	018	0	1	04	01	H5106_018_0	5	13	Group 13	01	000000000000000000000000000100010000		2		2			2		2	1			0	30				
H5106	018	0	1	04	01	H5106_018_0	5	10	Group 10	10		000000000000000000000001	1	500.00	2			2		2	1			0	0				
H5106	018	0	1	04	01	H5106_018_0	5	11	Group 11	01	000000100000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H5106	018	0	1	04	01	H5106_018_0	5	12	Group 12	01	000000000100000000000000000000000000		2		1	50.00	50.00	2		2	2								
H5106	018	0	1	04	01	H5106_018_0	5	9	Group 9	10		000000000000000010000000	2		2			1	500.00	2	1			50	50				
H5106	025	0	1	04	01	H5106_025_0	10	1	Group 1	11	000000000000000100000000000000000100	000000000000000000001000	2		2			2		1	1	1	30	0	30	30	2		
H5106	025	0	1	04	01	H5106_025_0	10	9	Group  9	10		000000000000000000000001	1	500.00	2			2		2	1			0	0				
H5106	025	0	1	04	01	H5106_025_0	10	8	Group 8	01	000000000000000000000000100000000000		2		2			2		2	1			0	50				
H5106	025	0	1	04	01	H5106_025_0	10	10	Group 10	01	000000000000000000000000000100010000		2		2			2		2	1			0	30				
H5106	025	0	1	04	01	H5106_025_0	10	6	Group 6	11	000000000000000000000000011000000000	000000010000000010000000	2		2			2		2	1			50	50				
H5106	025	0	1	04	01	H5106_025_0	10	3	Group 3	01	000000000000000000000000000000100000		2		2			2		1	1	1	30	0	0	30	2		
H5106	025	0	1	04	01	H5106_025_0	10	4	Group 4	11	011111111111111000011110000000001011	000000100000000000000110	2		2			2		2	1			30	30				
H5106	025	0	1	04	01	H5106_025_0	10	7	Group 7	01	000000000000000000000000000011000000		2		2			2		2	1			0	0				
H5106	025	0	1	04	01	H5106_025_0	10	5	Group 5	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	1			30	30				
H5106	025	0	1	04	01	H5106_025_0	10	2	Group 2	01	000000000000000011100000000000000000		2		2			2		1	1	1	30	0	30	30	2		
H5106	026	0	1	04	01	H5106_026_0	12	9	Group  9	10		000000000000000000000001	1	500.00	2			2		2	1			0	0				
H5106	026	0	1	04	01	H5106_026_0	12	8	Group 8	01	000000000000000000000000100000000000		2		2			2		2	1			0	50				
H5106	026	0	1	04	01	H5106_026_0	12	7	Group 7	01	000000000000000000000000000011000000		2		2			2		2	1			0	0				
H5106	026	0	1	04	01	H5106_026_0	12	6	Group 6	11	000000000000000000000000011000000000	000000010000000010000000	2		2			2		2	1			50	50				
H5106	026	0	1	04	01	H5106_026_0	12	5	Group 5	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	1			30	30				
H5106	026	0	1	04	01	H5106_026_0	12	4	Group 4	11	011111111111111000011110000000001011	000000100000000000000110	2		2			2		2	1			30	30				
H5106	026	0	1	04	01	H5106_026_0	12	2	Group 2	01	000000000000000011100000000000000000		2		2			2		1	1	1	30	0	30	30	2		
H5106	026	0	1	04	01	H5106_026_0	12	10	Group 10	01	000000000000000000000000000100010000		2		2			2		2	1			0	30				
H5106	026	0	1	04	01	H5106_026_0	12	1	Group 1	11	000000000000000100000000000000000100	000000000000000000001000	2		2			2		1	1	1	30	0	30	30	2		
H5106	026	0	1	04	01	H5106_026_0	12	3	Group 3	01	000000000000000000000000000000100000		2		2			2		1	1	1	30	0	0	30	2		
H5106	806	0	1	04	01	H5106_806_0	7	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H5106	806	0	1	04	01	H5106_806_0	7	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H5106	806	0	1	04	01	H5106_806_0	7	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H5106	807	0	1	04	01	H5106_807_0	7	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H5106	807	0	1	04	01	H5106_807_0	7	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H5106	807	0	1	04	01	H5106_807_0	7	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H5106	808	0	1	04	01	H5106_808_0	7	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H5106	808	0	1	04	01	H5106_808_0	7	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H5106	808	0	1	04	01	H5106_808_0	7	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H5141	001	0	1	04	01	H5141_001_0	14	3		10		000000000000000010000000	2		2			2		2	2								
H5141	001	0	1	04	01	H5141_001_0	14	2		10		000000000100000000000000	1	20.00	2			2		2	2								
H5141	001	0	1	04	01	H5141_001_0	14	1		01	011111111111111111111111111111111111		2		2			2		2	1			30	30				
H5141	003	0	1	04	01	H5141_003_0	12	3	Transportation	10		000000010000000000000000	2		2			2		2	2								
H5141	003	0	1	04	01	H5141_003_0	12	1	Medicare Covered	01	000001000000000000000000000010000000		2		2			2		2	2								
H5141	003	0	1	04	01	H5141_003_0	12	4		01	011100111101101011111111111101111111		2		2			2		2	1			20	20				
H5141	003	0	1	04	01	H5141_003_0	12	5		01	000000000000000100000000000000000000		2		2			2		2	1			0	20				
H5141	003	0	1	04	01	H5141_003_0	12	6		01	000010000010010000000000000000000000		2		2			2		2	1			35	35				
H5141	003	0	1	04	01	H5141_003_0	12	2	Over the Counter (OTC) Items	10		000000000100000000000000	1	25.00	2			2		2	2								
H5214	003	0	1	04	01	H5214_003_0	6	1		11	011111111111111111111100000001111101	000000000000000100000000	2		2			2		2	1			30	30				
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H5415	069	0	1	04	01	H5415_069_0	5	4		10		000000000110000010000000	2		2			2		2	1			50	50				
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H5415	069	0	1	04	01	H5415_069_0	5	1		11	011111111111111111111100111001101101	000000000000000100000000	2		2			2		2	1			30	30				
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H5415	070	0	1	04	01	H5415_070_0	5	2		11	000000000000000000000011000000000010	000000100000000000001100	2		1	0.00	0.00	2		2	2								
H5415	070	0	1	04	01	H5415_070_0	5	4		10		000000000110000010000000	2		2			2		2	1			50	50				
H5415	070	0	1	04	01	H5415_070_0	5	5		01	000000000000000000000000000000010000		2		2			2		2	1			20	30				
H5415	070	0	1	04	01	H5415_070_0	5	6		01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H5415	070	0	1	04	01	H5415_070_0	5	1		11	011111111111111111111100111001101101	000000000000000100000000	2		2			2		2	1			30	30				
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H5415	801	0	1	04	01	H5415_801_0	1	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H5415	801	0	1	04	01	H5415_801_0	1	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
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H5415	803	0	1	04	01	H5415_803_0	1	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
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H5415	804	0	1	04	01	H5415_804_0	1	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H5415	804	0	1	04	01	H5415_804_0	1	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
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H5415	806	0	2	04	01	H5415_806_0	1	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H5415	806	0	2	04	01	H5415_806_0	1	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
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H5415	807	0	2	04	01	H5415_807_0	1	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H5415	807	0	2	04	01	H5415_807_0	1	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H5415	808	0	2	04	01	H5415_808_0	1	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H5415	808	0	2	04	01	H5415_808_0	1	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H5415	808	0	2	04	01	H5415_808_0	1	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H5415	815	0	1	04	01	H5415_815_0	1	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H5415	815	0	1	04	01	H5415_815_0	1	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H5415	815	0	1	04	01	H5415_815_0	1	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H5417	001	0	1	04	01	H5417_001_0	6	3	Group 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H5417	001	0	1	04	01	H5417_001_0	6	1	Group 1	11	011111111111111011111111111001111101	000001100000000000001000	2		2			2		2	1			30	30				
H5417	001	0	1	04	01	H5417_001_0	6	2	Group 2	11	000000000000000000000000000000000010	000000000000000000110100	2		1	0.00	0.00	2		2	2								
H5417	001	0	1	04	01	H5417_001_0	6	5	Group 5	01	000000000000000100000000000010000000		2		2			2		2	1			0	30				
H5417	001	0	1	04	01	H5417_001_0	6	4	Group 4	10		000000010000000000000000	2		2			2		2	1			75	75				
H5424	001	0	1	04	01	H5424_001_0	7	4	Group 4	01	000000000000000100000000000000000000		2		1	13.00	13.00	2		2	1			30	30				
H5424	001	0	1	04	01	H5424_001_0	7	3	Group 3	11	000000000000000011011000011001110010	000000000001000100000000	2		2			2		2	1			30	30				
H5424	001	0	1	04	01	H5424_001_0	7	2	Group 2	11	011100011101001000000000000000001101	000011001000000000001010	2		1	45.00	45.00	2		2	2								
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H5424	001	0	1	04	01	H5424_001_0	7	13	Group 13	01	000000000000100000000000000000000000		2		1	25.00	45.00	2		2	2								
H5424	001	0	1	04	01	H5424_001_0	7	12	Group 12	01	000001000000000000000000100000000000		2		2			2		2	1			50	50				
H5424	001	0	1	04	01	H5424_001_0	7	7	Group 7	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H5424	001	0	1	04	01	H5424_001_0	7	10	Group 10	11	000000000000000000000010000000000000	000000100000000010000100	2		1	0.00	0.00	2		2	2								
H5424	001	0	1	04	01	H5424_001_0	7	1	Group 1	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H5424	001	0	1	04	01	H5424_001_0	7	8	Group 8	01	000000000010010000000100000000000000		2		1	35.00	45.00	2		2	2								
H5424	001	0	1	04	01	H5424_001_0	7	5	Group 5	01	000000000000000000100000000000000000		2		1	21.00	21.00	2		2	2								
H5424	001	0	1	04	01	H5424_001_0	7	9	Group 9	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H5424	001	0	1	04	01	H5424_001_0	7	6	Group 6	01	000010000000000000000000000000000000		2		1	75.00	75.00	2		2	2								
H5424	001	0	1	04	01	H5424_001_0	7	11	Group 11	01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H5424	003	0	1	04	01	H5424_003_0	3	9	Group 9	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H5424	003	0	1	04	01	H5424_003_0	3	8	Group 8	01	000000000010010000000100000000000000		2		1	35.00	45.00	2		2	2								
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H5424	003	0	1	04	01	H5424_003_0	3	5	Group 5	01	000000000000000000100000000000000000		2		1	21.00	21.00	2		2	2								
H5424	003	0	1	04	01	H5424_003_0	3	4	Group 4	01	000000000000000100000000000000000000		2		1	10.00	10.00	2		2	1			30	30				
H5424	003	0	1	04	01	H5424_003_0	3	3	Group 3	11	000000000000000011011000011001110010	000000000001000100000000	2		2			2		2	1			30	30				
H5424	003	0	1	04	01	H5424_003_0	3	2	Group 2	11	011100011101001000000000000000001101	000011001000000000001010	2		1	45.00	45.00	2		2	2								
H5424	003	0	1	04	01	H5424_003_0	3	14	Group 14	10		000000000000000000000001	2		1	100.00	150.00	2		2	2								
H5424	003	0	1	04	01	H5424_003_0	3	13	Group 13	01	000000000000100000000000000000000000		2		1	25.00	45.00	2		2	2								
H5424	003	0	1	04	01	H5424_003_0	3	12	Group 12	01	000001000000000000000000100000000000		2		2			2		2	1			50	50				
H5424	003	0	1	04	01	H5424_003_0	3	11	Group 11	01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H5424	003	0	1	04	01	H5424_003_0	3	10	Group 10	11	000000000000000000000010000000000000	000000100000000010000100	2		1	0.00	0.00	2		2	2								
H5424	003	0	1	04	01	H5424_003_0	3	1	Group 1	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H5424	003	0	1	04	01	H5424_003_0	3	7	Group 7	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H5424	005	0	1	04	01	H5424_005_0	7	3	Group 3	01	000000000000000000000000000100010000		2		2			2		2	1			20	20				
H5424	005	0	1	04	01	H5424_005_0	7	2	Group 2	01	000000000000000100000000000010000000		2		2			2		2	1			0	30				
H5424	005	0	1	04	01	H5424_005_0	7	1	Group 1	11	011111111111111011111111111001101101	000001100000000000000000	2		2			2		2	1			30	30				
H5424	005	0	1	04	01	H5424_005_0	7	4	Group 4	11	000000000000000000000000000000000010	000000000100000000110000	2		1	0.00	0.00	2		2	2								
H5434	002	0	1	04	01	H5434_002_0	10	7	Eye wear	10		000000000000000000000100	1	125.00	1	20.00	20.00	2		2	2								
H5434	002	0	1	04	01	H5434_002_0	10	6	Dental	11	000000000000000000000000000000001000	000000000000000000110000	2		2			2		2	1			30	50				
H5434	002	0	1	04	01	H5434_002_0	10	5	0 copayment	10		000000000000000010001011	2		2			2		2	2								
H5434	002	0	1	04	01	H5434_002_0	10	4	Renal Dialysis	01	000000000000000000000000000100000000		2		1	25.00	25.00	2		2	1			20	20				
H5434	002	0	1	04	01	H5434_002_0	10	3	Ambulance	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H5434	002	0	1	04	01	H5434_002_0	10	2	50% coinsurance	01	000001000000000000000000101000010000		2		2			2		2	1			50	50				
H5434	002	0	1	04	01	H5434_002_0	10	1	30% coinsurance	11	011110111111111111111110110011100111	000001100000000000000000	2		2			2		2	1			30	30				
H5434	801	0	1	04	01	H5434_801_0	5	2	All Other	01	011110111111111111111111111111111111		2		2			2		2	1			22	22				
H5434	801	0	1	04	01	H5434_801_0	5	1	$0 coinsurance	01	000001000000000000000000000010000000		2		2			2		2	2								
H5434	802	0	1	04	01	H5434_802_0	3	2	All Other	01	011110111111111111111111111111111111		2		2			2		2	1			22	22				
H5434	802	0	1	04	01	H5434_802_0	3	1	$0 coinsurance	01	000001000000000000000000000010000000		2		2			2		2	2								
H5439	001	0	1	04	01	H5439_001_0	5	8	Group 8 - $40	01	000000000100100000000000000000000000		2		1	40.00	40.00	2		2	2								
H5439	001	0	1	04	01	H5439_001_0	5	7	Group 7 - $30	01	000000100000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H5439	001	0	1	04	01	H5439_001_0	5	6	Group 6 - 15%	01	000000000000000000000000110000010000		2		2			2		2	1			15	15				
H5439	001	0	1	04	01	H5439_001_0	5	5	Group 5 - $50	01	000010010010010000000100000000000000		2		1	50.00	50.00	2		2	2								
H5439	001	0	1	04	01	H5439_001_0	5	4	Group 4 - $0	11	000000000000000000000000000000000010	000000000000000010000000	2		1	0.00	0.00	2		2	2								
H5439	001	0	1	04	01	H5439_001_0	5	3	Group 3 - $35	01	011100001001001000000000000000000000		2		1	35.00	35.00	2		2	2								
H5439	001	0	1	04	01	H5439_001_0	5	2	Group 2 - $275	01	000000000000000000000001000000000000		2		1	275.00	275.00	2		2	2								
H5439	001	0	1	04	01	H5439_001_0	5	12	Group 12 - 0% or 10%	11	000000000000000000000000000010000100	000000000000000000001000	2		2			2		2	1			0	10				
H5439	001	0	1	04	01	H5439_001_0	5	11	Group 11 - 15% or 20%	01	000000000000000000000000001000000000		2		2			2		2	1			15	20				
H5439	001	0	1	04	01	H5439_001_0	5	10	Group 10 - 5%	01	000001000000000000000000000000000000		2		2			2		2	1			5	5				
H5439	001	0	1	04	01	H5439_001_0	5	9	Group 9 - 30%	01	000000000000000000011000000000000000		2		2			2		2	1			30	30				
H5439	001	0	1	04	01	H5439_001_0	5	1	Group 1 - 10%	11	000000000000000111100010000101101001	000000100001000000000010	2		2			2		2	1			10	10				
H5439	002	0	1	04	01	H5439_002_0	5	7	Group 7 - 10% or 20%	01	000000000000000000000000001000000000		2		2			2		2	1			10	20				
H5439	002	0	1	04	01	H5439_002_0	5	8	Group 8 - 10%	01	000000000000000000000000110100010000		2		2			2		2	1			10	10				
H5439	002	0	1	04	01	H5439_002_0	5	9	Group 9 - 0% or 15%	01	000000000000000000000000000010000000		2		2			2		2	1			0	15				
H5439	002	0	1	04	01	H5439_002_0	5	1	Group 1 - $30	01	000000100000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H5439	002	0	1	04	01	H5439_002_0	5	2	Group 2 - $250	01	000000000000000000000001000000000000		2		1	250.00	250.00	2		2	2								
H5439	002	0	1	04	01	H5439_002_0	5	3	Group 3 - $40	01	011110011111111000000000000000000000		2		1	40.00	40.00	2		2	2								
H5439	002	0	1	04	01	H5439_002_0	5	4	Group 4 - $0	11	000001000000000000000000000000001010	000000000000000010000000	2		1	0.00	0.00	2		2	2								
H5439	002	0	1	04	01	H5439_002_0	5	5	Group 5 - 0% or 30%	11	000000000000000000000000000000000100	000000000000000000001000	2		2			2		2	1			0	30				
H5439	002	0	1	04	01	H5439_002_0	5	6	Group 6 - 30%	11	000000000000000111111110000001100001	000000100001000000000000	2		2			2		2	1			30	30				
H5439	801	0	1	04	01	H5439_801_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
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H5509	017	0	1	04	01	H5509_017_0	9	4		10		000000000000000010000000	2		1	0.00	50.00	2		2	2								
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H5509	018	0	1	04	01	H5509_018_0	12	4		10		000000000000000010000000	2		1	0.00	50.00	2		2	2								
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H5516	001	0	1	04	01	H5516_001_0	7	7	Group 7	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
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H5516	001	0	1	04	01	H5516_001_0	7	9	Group 9	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H5516	001	0	1	04	01	H5516_001_0	7	1	Group 1	01	000000100000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H5516	001	0	1	04	01	H5516_001_0	7	10	Group 10	11	000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2	2								
H5516	001	0	1	04	01	H5516_001_0	7	11	Group 11	01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H5516	001	0	1	04	01	H5516_001_0	7	6	Group 6	01	000010000000000000000000000000000000		2		1	75.00	75.00	2		2	2								
H5516	001	0	1	04	01	H5516_001_0	7	13	Group 14	01	000000000000100000000000000000000000		2		1	30.00	45.00	2		2	2								
H5516	001	0	1	04	01	H5516_001_0	7	14	Group 14	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H5516	001	0	1	04	01	H5516_001_0	7	2	Group 2	11	011100011101001000000000000000001101	000001000000000000001010	2		1	45.00	45.00	2		2	2								
H5516	001	0	1	04	01	H5516_001_0	7	3	Group 3	11	000000000000000011011000011001110010	000000000001000100000000	2		2			2		2	1			30	30				
H5516	001	0	1	04	01	H5516_001_0	7	4	Group 4	01	000000000000000100000000000000000000		2		1	13.00	13.00	2		2	1			30	30				
H5516	001	0	1	04	01	H5516_001_0	7	5	Group 5	01	000000000000000000100000000000000000		2		1	21.00	21.00	2		2	2								
H5516	001	0	1	04	01	H5516_001_0	7	12	Group 12	01	000001000000000000000000100000000000		2		2			2		2	1			50	50				
H5520	001	0	1	04	01	H5520_001_0	4	1	Group $20	01	000000100101100000000000000000000001		2		1	20.00	20.00	2		2	2								
H5520	001	0	1	04	01	H5520_001_0	4	10	Group $175	01	000000000000000000001000000000000000		2		1	175.00	175.00	2		2	2								
H5520	001	0	1	04	01	H5520_001_0	4	11	Group $0	11	000011000000000000000010000011100010	000000100001000010000100	2		1	0.00	0.00	2		2	2								
H5520	001	0	1	04	01	H5520_001_0	4	12	Group $0 or 0% - 20%	01	000000000000000100000000000000000000		2		1	0.00	0.00	2		1	1	2		0	20		1	20.00	20.00
H5520	001	0	1	04	01	H5520_001_0	4	13	Group $0 or 20%	01	000000000000000000000000001000000000		2		1	0.00	0.00	2		2	1			20	20				
H5520	001	0	1	04	01	H5520_001_0	4	14	Group $20 w Physician/Professional Serv	01	000000000000000000100000000000000000		2		1	20.00	20.00	2		1	2	2					1	20.00	20.00
H5520	001	0	1	04	01	H5520_001_0	4	9	Group $200	01	000000000000000000010000000000000000		2		1	200.00	200.00	2		2	2								
H5520	001	0	1	04	01	H5520_001_0	4	3	Group $50	01	000000000010010000000100000000000000		2		1	50.00	50.00	2		2	2								
H5520	001	0	1	04	01	H5520_001_0	4	4	Group 20%	01	000000000000000011000000110100010000		2		2			2		2	1			20	20				
H5520	001	0	1	04	01	H5520_001_0	4	5	Group $0 - $20	11	000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	20.00	2		2	2								
H5520	001	0	1	04	01	H5520_001_0	4	6	Group $20 - $65	01	000000000000000000000000000000001000		2		1	20.00	65.00	2		2	2								
H5520	001	0	1	04	01	H5520_001_0	4	7	Group $100	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H5520	001	0	1	04	01	H5520_001_0	4	8	Group $15	11	000000010000000000000000000000000000	000010001000000000000000	2		1	15.00	15.00	2		2	2								
H5520	001	0	1	04	01	H5520_001_0	4	2	Group $35	01	011100001000001000000000000000000000		2		1	35.00	35.00	2		2	2								
H5520	002	0	1	04	01	H5520_002_0	5	1	Group $20	01	000000100100100000000000000000000001		2		1	20.00	20.00	2		2	2								
H5520	002	0	1	04	01	H5520_002_0	5	9	Group $200	01	000000000000000000010000000000000000		2		1	200.00	200.00	2		2	2								
H5520	002	0	1	04	01	H5520_002_0	5	11	Group $20 or 0% - 18%	01	000000000000000100000000000000000000		2		1	20.00	20.00	2		1	1	2		0	18		1	20.00	20.00
H5520	002	0	1	04	01	H5520_002_0	5	12	Group $0 or 18%	01	000000000000000000000000001000000000		2		1	0.00	0.00	2		2	1			18	18				
H5520	002	0	1	04	01	H5520_002_0	5	13	Group $0 - $20	11	000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	20.00	2		2	2								
H5520	002	0	1	04	01	H5520_002_0	5	14	Group $20 - $35	11	000000000001000000000000000000000000	000001000000000000000000	2		1	20.00	35.00	2		2	2								
H5520	002	0	1	04	01	H5520_002_0	5	15	Group $20 w Physician/Professional Serv	01	000000000000000000100000000000000000		2		1	20.00	20.00	2		1	2	2					1	20.00	20.00
H5520	002	0	1	04	01	H5520_002_0	5	2	Group $35	01	011100001000001000000000000000000000		2		1	35.00	35.00	2		2	2								
H5520	002	0	1	04	01	H5520_002_0	5	3	Group $50	01	000000000010010000000100000000000000		2		1	50.00	50.00	2		2	2								
H5520	002	0	1	04	01	H5520_002_0	5	4	Group 18%	01	000000000000000011000000110000010000		2		2			2		2	1			18	18				
H5520	002	0	1	04	01	H5520_002_0	5	5	Group 20%	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H5520	002	0	1	04	01	H5520_002_0	5	6	Group $20 - $65	01	000000000000000000000000000000001000		2		1	20.00	65.00	2		2	2								
H5520	002	0	1	04	01	H5520_002_0	5	7	Group $175	01	000000000000000000001001000000000000		2		1	175.00	175.00	2		2	2								
H5520	002	0	1	04	01	H5520_002_0	5	8	Group $15	11	000000010000000000000000000000000000	000010001000000000000000	2		1	15.00	15.00	2		2	2								
H5520	002	0	1	04	01	H5520_002_0	5	10	Group $0	11	000011000000000000000010000011100010	000000100001000010000100	2		1	0.00	0.00	2		2	2								
H5520	003	0	1	04	01	H5520_003_0	4	1	Group $20	01	000000100101100000000000000000000001		2		1	20.00	20.00	2		2	2								
H5520	003	0	1	04	01	H5520_003_0	4	10	Group $175	01	000000000000000000001000000000000000		2		1	175.00	175.00	2		2	2								
H5520	003	0	1	04	01	H5520_003_0	4	11	Group $0	11	000011000000000000000010000011100010	000000100001000010000100	2		1	0.00	0.00	2		2	2								
H5520	003	0	1	04	01	H5520_003_0	4	12	Group $0 or 0% - 20%	01	000000000000000100000000000000000000		2		1	0.00	0.00	2		1	1	2		0	20		1	20.00	20.00
H5520	003	0	1	04	01	H5520_003_0	4	13	Group $0 or 20%	01	000000000000000000000000001000000000		2		1	0.00	0.00	2		2	1			20	20				
H5520	003	0	1	04	01	H5520_003_0	4	14	Group $20 w Physician/Professional Serv	01	000000000000000000100000000000000000		2		1	20.00	20.00	2		1	2	2					1	20.00	20.00
H5520	003	0	1	04	01	H5520_003_0	4	9	Group $200	01	000000000000000000010000000000000000		2		1	200.00	200.00	2		2	2								
H5520	003	0	1	04	01	H5520_003_0	4	3	Group $50	01	000000000010010000000100000000000000		2		1	50.00	50.00	2		2	2								
H5520	003	0	1	04	01	H5520_003_0	4	4	Group 20%	01	000000000000000011000000110100010000		2		2			2		2	1			20	20				
H5520	003	0	1	04	01	H5520_003_0	4	5	Group $0 - $20	11	000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	20.00	2		2	2								
H5520	003	0	1	04	01	H5520_003_0	4	6	Group $20 - $65	01	000000000000000000000000000000001000		2		1	20.00	65.00	2		2	2								
H5520	003	0	1	04	01	H5520_003_0	4	7	Group $100	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H5520	003	0	1	04	01	H5520_003_0	4	8	Group $15	11	000000010000000000000000000000000000	000010001000000000000000	2		1	15.00	15.00	2		2	2								
H5520	003	0	1	04	01	H5520_003_0	4	2	Group $35	01	011100001000001000000000000000000000		2		1	35.00	35.00	2		2	2								
H5520	004	0	1	04	01	H5520_004_0	5	1	Group $20	01	000000100100100000000000000000000001		2		1	20.00	20.00	2		2	2								
H5520	004	0	1	04	01	H5520_004_0	5	9	Group $200	01	000000000000000000010000000000000000		2		1	200.00	200.00	2		2	2								
H5520	004	0	1	04	01	H5520_004_0	5	11	Group $20 or 0% - 18%	01	000000000000000100000000000000000000		2		1	20.00	20.00	2		1	1	2		0	18		1	20.00	20.00
H5520	004	0	1	04	01	H5520_004_0	5	12	Group $0 or 18%	01	000000000000000000000000001000000000		2		1	0.00	0.00	2		2	1			18	18				
H5520	004	0	1	04	01	H5520_004_0	5	13	Group $0 - $20	11	000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	20.00	2		2	2								
H5520	004	0	1	04	01	H5520_004_0	5	14	Group $20 - $35	11	000000000001000000000000000000000000	000001000000000000000000	2		1	20.00	35.00	2		2	2								
H5520	004	0	1	04	01	H5520_004_0	5	15	Group $20 w Physician/Professional Serv	01	000000000000000000100000000000000000		2		1	20.00	20.00	2		1	2	2					1	20.00	20.00
H5520	004	0	1	04	01	H5520_004_0	5	2	Group $35	01	011100001000001000000000000000000000		2		1	35.00	35.00	2		2	2								
H5520	004	0	1	04	01	H5520_004_0	5	3	Group $50	01	000000000010010000000100000000000000		2		1	50.00	50.00	2		2	2								
H5520	004	0	1	04	01	H5520_004_0	5	4	Group 18%	01	000000000000000011000000110000010000		2		2			2		2	1			18	18				
H5520	004	0	1	04	01	H5520_004_0	5	5	Group 20%	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H5520	004	0	1	04	01	H5520_004_0	5	6	Group $20 - $65	01	000000000000000000000000000000001000		2		1	20.00	65.00	2		2	2								
H5520	004	0	1	04	01	H5520_004_0	5	7	Group $175	01	000000000000000000001001000000000000		2		1	175.00	175.00	2		2	2								
H5520	004	0	1	04	01	H5520_004_0	5	8	Group $15	11	000000010000000000000000000000000000	000010001000000000000000	2		1	15.00	15.00	2		2	2								
H5520	004	0	1	04	01	H5520_004_0	5	10	Group $0	11	000011000000000000000010000011100010	000000100001000010000100	2		1	0.00	0.00	2		2	2								
H5520	005	0	1	04	01	H5520_005_0	5	1	Group $20	01	000000100101100000000000000000000001		2		1	20.00	20.00	2		2	2								
H5520	005	0	1	04	01	H5520_005_0	5	10	Group $0	11	000011000000000000000010000011100000	000000100001000010000000	2		1	0.00	0.00	2		2	2								
H5520	005	0	1	04	01	H5520_005_0	5	11	Group $20 or 0% - 20%	01	000000000000000100000000000000000000		2		1	20.00	20.00	2		1	1	2		0	20		1	20.00	20.00
H5520	005	0	1	04	01	H5520_005_0	5	12	Group $0 or 20%	01	000000000000000000000000001000000000		2		1	0.00	0.00	2		2	1			20	20				
H5520	005	0	1	04	01	H5520_005_0	5	2	Group $35	01	011100001000001000000000000000000000		2		1	35.00	35.00	2		2	2								
H5520	005	0	1	04	01	H5520_005_0	5	9	Group $20 w Physician/Professional Serv	01	000000000000000000100000000000000000		2		1	20.00	20.00	2		1	2	2					1	20.00	20.00
H5520	005	0	1	04	01	H5520_005_0	5	4	Group 20%	01	000000000000000011011000110100010010		2		2			2		2	1			20	20				
H5520	005	0	1	04	01	H5520_005_0	5	5	Group $20 - $65	01	000000000000000000000000000000001000		2		1	20.00	65.00	2		2	2								
H5520	005	0	1	04	01	H5520_005_0	5	6	Group $250	01	000000000000000000000001000000000000		2		1	250.00	250.00	2		2	2								
H5520	005	0	1	04	01	H5520_005_0	5	7	Group $15	11	000000010000000000000000000000000000	000010001000000000000000	2		1	15.00	15.00	2		2	2								
H5520	005	0	1	04	01	H5520_005_0	5	8	Group $0 - $20	01	000000000000000000000000000000000100		2		1	0.00	20.00	2		2	2								
H5520	005	0	1	04	01	H5520_005_0	5	3	Group $50	01	000000000010010000000100000000000000		2		1	50.00	50.00	2		2	2								
H5520	006	0	1	04	01	H5520_006_0	5	1	Group $20	01	000000100101100000000000000000000001		2		1	20.00	20.00	2		2	2								
H5520	006	0	1	04	01	H5520_006_0	5	10	Group $0	11	000011000000000000000010000011100000	000000100001000010000000	2		1	0.00	0.00	2		2	2								
H5520	006	0	1	04	01	H5520_006_0	5	11	Group $20 or 0% - 20%	01	000000000000000100000000000000000000		2		1	20.00	20.00	2		1	1	2		0	20		1	20.00	20.00
H5520	006	0	1	04	01	H5520_006_0	5	12	Group $0 or 20%	01	000000000000000000000000001000000000		2		1	0.00	0.00	2		2	1			20	20				
H5520	006	0	1	04	01	H5520_006_0	5	2	Group $35	01	011100001000001000000000000000000000		2		1	35.00	35.00	2		2	2								
H5520	006	0	1	04	01	H5520_006_0	5	9	Group $20 w Physician/Prefessional Serv	01	000000000000000000100000000000000000		2		1	20.00	20.00	2		1	2	2					1	20.00	20.00
H5520	006	0	1	04	01	H5520_006_0	5	4	Group 20%	01	000000000000000011011000110100010010		2		2			2		2	1			20	20				
H5520	006	0	1	04	01	H5520_006_0	5	5	Group $20 - $65	01	000000000000000000000000000000001000		2		1	20.00	65.00	2		2	2								
H5520	006	0	1	04	01	H5520_006_0	5	6	Group $250	01	000000000000000000000001000000000000		2		1	250.00	250.00	2		2	2								
H5520	006	0	1	04	01	H5520_006_0	5	7	Group $15	11	000000010000000000000000000000000000	000010001000000000000000	2		1	15.00	15.00	2		2	2								
H5520	006	0	1	04	01	H5520_006_0	5	8	Group $0 - $20	01	000000000000000000000000000000000100		2		1	0.00	20.00	2		2	2								
H5520	006	0	1	04	01	H5520_006_0	5	3	Group $50	01	000000000010010000000100000000000000		2		1	50.00	50.00	2		2	2								
H5520	009	0	1	04	01	H5520_009_0	5	5	Group $50	01	000000000010010000000100000000000000		2		1	50.00	50.00	2		2	2								
H5520	009	0	1	04	01	H5520_009_0	5	6	Group $150	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H5520	009	0	1	04	01	H5520_009_0	5	7	Group $200	01	000000000000000000010000000000000000		2		1	200.00	200.00	2		2	2								
H5520	009	0	1	04	01	H5520_009_0	5	8	Group 12%	01	000000000000000011000000110000010000		2		2			2		2	1			12	12				
H5520	009	0	1	04	01	H5520_009_0	5	9	Group 20% + $35 Deductible	10		000000000000000000100000	1	500.00	2			1	35.00	2	1			20	20				
H5520	009	0	1	04	01	H5520_009_0	5	1	Group $0	11	000011000000000000100010000011100010	000000100001000010000101	2		1	0.00	0.00	2		2	2								
H5520	009	0	1	04	01	H5520_009_0	5	10	Group $0 or 0% - 12%	01	000000000000000100000000000000000000		2		1	0.00	0.00	2		1	1	2		0	12		1	20.00	20.00
H5520	009	0	1	04	01	H5520_009_0	5	11	Group $20 - $65	01	000000000000000000000000000000001000		2		1	20.00	65.00	2		2	2								
H5520	009	0	1	04	01	H5520_009_0	5	12	Group $100	01	000000000000000000001000000000000000		2		1	100.00	100.00	2		2	2								
H5520	009	0	1	04	01	H5520_009_0	5	13	Group $0 or 12%	01	000000000000000000000000001000000000		2		1	0.00	0.00	2		2	1			12	12				
H5520	009	0	1	04	01	H5520_009_0	5	14	Group $0 - $20	11	000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	20.00	2		2	2								
H5520	009	0	1	04	01	H5520_009_0	5	15	Group 20%	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H5520	009	0	1	04	01	H5520_009_0	5	2	Group $20	01	000000100101100000000000000000000001		2		1	20.00	20.00	2		2	2								
H5520	009	0	1	04	01	H5520_009_0	5	3	Group $15	11	000000010000000000000000000000000000	000010001000000000000000	2		1	15.00	15.00	2		2	2								
H5520	009	0	1	04	01	H5520_009_0	5	4	Group $35	01	011100001000001000000000000000000000		2		1	35.00	35.00	2		2	2								
H5520	010	0	1	04	01	H5520_010_0	5	1	Group $0	11	000011000000000000100010000011100010	000000100001000010000101	2		1	0.00	0.00	2		2	2								
H5520	010	0	1	04	01	H5520_010_0	5	10	Group $0 or 0% - 12%	01	000000000000000100000000000000000000		2		1	0.00	0.00	2		1	1	2		0	12		1	10.00	10.00
H5520	010	0	1	04	01	H5520_010_0	5	9	Group 20% + $35 Deductible	10		000000000000000000100000	1	500.00	2			1	35.00	2	1			20	20				
H5520	010	0	1	04	01	H5520_010_0	5	8	Group 12%	01	000000000000000011000000110000010000		2		2			2		2	1			12	12				
H5520	010	0	1	04	01	H5520_010_0	5	7	Group $125	01	000000000000000000010000000000000000		2		1	125.00	125.00	2		2	2								
H5520	010	0	1	04	01	H5520_010_0	5	6	Group $100	01	000000000000000000001000000000000000		2		1	100.00	100.00	2		2	2								
H5520	010	0	1	04	01	H5520_010_0	5	5	Group $50	01	000000000010010000000100000000000000		2		1	50.00	50.00	2		2	2								
H5520	010	0	1	04	01	H5520_010_0	5	4	Group $35	01	011100001000001000000000000000000000		2		1	35.00	35.00	2		2	2								
H5520	010	0	1	04	01	H5520_010_0	5	3	Group $15	11	000000010000000000000000000000000000	000010001000000000000000	2		1	15.00	15.00	2		2	2								
H5520	010	0	1	04	01	H5520_010_0	5	2	Group $10	01	000000100101100000000000000000000001		2		1	10.00	10.00	2		2	2								
H5520	010	0	1	04	01	H5520_010_0	5	11	Group $10 - $65	01	000000000000000000000000000000001000		2		1	10.00	65.00	2		2	2								
H5520	010	0	1	04	01	H5520_010_0	5	12	Group $0 - $10	11	000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	10.00	2		2	2								
H5520	010	0	1	04	01	H5520_010_0	5	13	Group $0 or 12%	01	000000000000000000000000001000000000		2		1	0.00	0.00	2		2	1			12	12				
H5520	010	0	1	04	01	H5520_010_0	5	14	Group 20%	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H5520	010	0	1	04	01	H5520_010_0	5	15	Group $175	01	000000000000000000000001000000000000		2		1	175.00	175.00	2		2	2								
H5520	807	0	1	04	01	H5520_807_0	1	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H5520	807	0	1	04	01	H5520_807_0	1	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H5520	807	0	1	04	01	H5520_807_0	1	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H5520	808	0	1	04	01	H5520_808_0	1	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H5520	808	0	1	04	01	H5520_808_0	1	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H5520	808	0	1	04	01	H5520_808_0	1	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H5520	809	0	1	04	01	H5520_809_0	1	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H5520	809	0	1	04	01	H5520_809_0	1	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H5520	809	0	1	04	01	H5520_809_0	1	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H5521	012	0	1	04	01	H5521_012_0	6	1	Tier 1	11	011111111111111111111110111011111111	000000000001000000001010	2		2			2		2	1			25	25				
H5521	012	0	1	04	01	H5521_012_0	6	2	Tier 2	01	000000000000000000000001000000000000		2		1	225.00	225.00	2		2	2								
H5521	012	0	1	04	01	H5521_012_0	6	3	Tier 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H5521	012	0	1	04	01	H5521_012_0	6	4	Tier 4	10		000000000000100010000000	2		2			2		2	2								
H5521	013	0	1	04	01	H5521_013_0	6	1	Tier 1	11	011111111111111111111110111011111111	000000000001000000001010	2		2			2		2	1			30	30				
H5521	013	0	1	04	01	H5521_013_0	6	2	Tier 2	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H5521	013	0	1	04	01	H5521_013_0	6	3	Tier 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H5521	013	0	1	04	01	H5521_013_0	6	4	Tier 4	10		000000000000100010000101	2		2			2		2	2								
H5521	015	0	1	04	01	H5521_015_0	7	1	Tier 1	11	011111111111111111111110111011111111	000000000001000000001010	2		2			2		2	1			30	30				
H5521	015	0	1	04	01	H5521_015_0	7	2	Tier 2	01	000000000000000000000001000000000000		2		1	175.00	175.00	2		2	2								
H5521	015	0	1	04	01	H5521_015_0	7	3	Tier 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H5521	015	0	1	04	01	H5521_015_0	7	4	Tier 4	10		000000000000100010000100	2		2			2		2	2								
H5521	016	0	1	04	01	H5521_016_0	6	1	Tier 1	11	011111111111111111111110111011111111	000000000001000000001010	2		2			2		2	1			30	30				
H5521	016	0	1	04	01	H5521_016_0	6	4	Tier 4	10		000000000000100010000000	2		2			2		2	2								
H5521	016	0	1	04	01	H5521_016_0	6	2	Tier 2	01	000000000000000000000001000000000000		2		1	175.00	175.00	2		2	2								
H5521	016	0	1	04	01	H5521_016_0	6	3	Tier 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H5521	020	0	1	04	01	H5521_020_0	8	1	Tier 1	11	011111111111111111111110111011111111	000000000001000000001010	2		2			2		2	1			25	25				
H5521	020	0	1	04	01	H5521_020_0	8	3	Tier 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H5521	020	0	1	04	01	H5521_020_0	8	4	Tier 4	10		000000000000100010000100	2		2			2		2	2								
H5521	020	0	1	04	01	H5521_020_0	8	2	Tier 2	01	000000000000000000000001000000000000		2		1	180.00	180.00	2		2	2								
H5521	022	0	1	04	01	H5521_022_0	8	1	Tier 1	11	011111111111111111111110111011111111	000000000001000000001010	2		2			2		2	1			30	30				
H5521	022	0	1	04	01	H5521_022_0	8	2	Tier 2	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H5521	022	0	1	04	01	H5521_022_0	8	3	Tier 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H5521	022	0	1	04	01	H5521_022_0	8	4	Tier 4	10		000000000000100010000000	2		2			2		2	2								
H5521	027	0	1	04	01	H5521_027_0	6	1	Tier 1	11	011111111111111111111110111011111111	000000000001000000001010	2		2			2		2	1			30	30				
H5521	027	0	1	04	01	H5521_027_0	6	4	Tier 4	10		000000000000100010000100	2		2			2		2	2								
H5521	027	0	1	04	01	H5521_027_0	6	3	Tier 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H5521	027	0	1	04	01	H5521_027_0	6	2	Tier 2	01	000000000000000000000001000000000000		2		1	175.00	175.00	2		2	2								
H5521	028	0	1	04	01	H5521_028_0	6	3	Tier 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H5521	028	0	1	04	01	H5521_028_0	6	2	Tier 2	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H5521	028	0	1	04	01	H5521_028_0	6	1	Tier 1	11	011111111111111111111110111011111111	000000000001000000001010	2		2			2		2	1			30	30				
H5521	028	0	1	04	01	H5521_028_0	6	4	Tier 4	10		000000000000100010000000	2		2			2		2	2								
H5521	033	0	1	04	01	H5521_033_0	6	2	Tier 2	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H5521	033	0	1	04	01	H5521_033_0	6	4	Tier 4	10		000000000000100010000101	2		2			2		2	2								
H5521	033	0	1	04	01	H5521_033_0	6	3	Tier 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H5521	033	0	1	04	01	H5521_033_0	6	1	Tier 1	11	011111111111111111111110111011111111	000000000001000000001010	2		2			2		2	1			30	30				
H5521	036	0	1	04	01	H5521_036_0	7	1	Tier 1	11	011111111111111111111110111011111111	000000000001000000001010	2		2			2		2	1			35	35				
H5521	036	0	1	04	01	H5521_036_0	7	2	Tier 2	01	000000000000000000000001000000000000		2		1	175.00	175.00	2		2	2								
H5521	036	0	1	04	01	H5521_036_0	7	3	Tier 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H5521	036	0	1	04	01	H5521_036_0	7	4	Tier 4	10		000000000000100010000100	2		2			2		2	2								
H5521	037	0	1	04	01	H5521_037_0	5	4	Tier 4	10		000000000000100010000101	2		2			2		2	2								
H5521	037	0	1	04	01	H5521_037_0	5	3	Tier 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H5521	037	0	1	04	01	H5521_037_0	5	2	Tier 2	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H5521	037	0	1	04	01	H5521_037_0	5	1	Tier 1	11	011111111111111111111110111011111111	000000000001000000001010	2		2			2		2	1			30	30				
H5521	038	0	1	04	01	H5521_038_0	5	2	Tier 2	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H5521	038	0	1	04	01	H5521_038_0	5	3	Tier 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H5521	038	0	1	04	01	H5521_038_0	5	4	Tier 4	10		000000000000100010000101	2		2			2		2	2								
H5521	038	0	1	04	01	H5521_038_0	5	1	Tier 1	11	011111111111111111111110111011111111	000000000001000000001010	2		2			2		2	1			35	35				
H5521	040	0	1	04	01	H5521_040_0	6	4	Tier 4	10		000000000000100010000100	2		2			2		2	2								
H5521	040	0	1	04	01	H5521_040_0	6	3	Tier 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H5521	040	0	1	04	01	H5521_040_0	6	2	Tier 2	01	000000000000000000000001000000000000		2		1	225.00	225.00	2		2	2								
H5521	040	0	1	04	01	H5521_040_0	6	1	Tier 1	11	011111111111111111111110111011111111	000000000001000000001010	2		2			2		2	1			40	40				
H5521	801	0	1	04	01	H5521_801_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H5521	801	0	1	04	01	H5521_801_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H5521	801	0	1	04	01	H5521_801_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H5521	802	0	1	04	01	H5521_802_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H5521	802	0	1	04	01	H5521_802_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H5521	802	0	1	04	01	H5521_802_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H5521	805	0	2	04	01	H5521_805_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H5521	805	0	2	04	01	H5521_805_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H5521	805	0	2	04	01	H5521_805_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H5521	806	0	2	04	01	H5521_806_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H5521	806	0	2	04	01	H5521_806_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H5521	806	0	2	04	01	H5521_806_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H5522	001	0	1	04	01	H5522_001_0	10	3	45% Coinsurance OON	01	000010000010010000000100000000000000		2		2			2		2	1			45	45				
H5522	001	0	1	04	01	H5522_001_0	10	4	GYM OON Monthly Copay	10		000000000000000010000000	2		1	50.00	50.00	2		2	2								
H5522	001	0	1	04	01	H5522_001_0	10	5	Ambulance OON	01	000000000000000000000001000000000000		2		1	75.00	75.00	2		2	2								
H5522	001	0	1	04	01	H5522_001_0	10	6	50% Coinsurance	10		000000000000000000000001	2		2			2		2	1			50	50				
H5522	001	0	1	04	01	H5522_001_0	10	7	30% Coinsurance	10		000000000000000000100000	2		2			1	100.00	2	1			30	30				
H5522	001	0	1	04	01	H5522_001_0	10	8	50% Non-Medicare Dental Coinsurance	10		000000000000000000010000	2		2			1	100.00	2	1			50	50				
H5522	001	0	1	04	01	H5522_001_0	10	9	0%- 20%	01	000000000000000000000000000010000000		2		2			2		2	1			0	20				
H5522	001	0	1	04	01	H5522_001_0	10	1	0% Coinsurance OON	01	000001000000000000000000000000000000		2		2			2		2	1			0	0				
H5522	001	0	1	04	01	H5522_001_0	10	2	20% Coinsurance OON	11	011100111101101111111010111101111111	000001100001000000001010	2		2			2		2	1			20	20				
H5522	002	0	1	04	01	H5522_002_0	7	2	20% Coinsurance OON	11	011100111101101111111010111101111111	000001100001000000001010	2		2			2		2	1			20	20				
H5522	002	0	1	04	01	H5522_002_0	7	3	45% Coinsurance OON	01	000010000010010000000100000000000000		2		2			2		2	1			45	45				
H5522	002	0	1	04	01	H5522_002_0	7	4	GYM OON Monthly Copay	10		000000000000000010000000	2		1	50.00	50.00	2		2	2								
H5522	002	0	1	04	01	H5522_002_0	7	5	Ambulance OON	01	000000000000000000000001000000000000		2		1	125.00	125.00	2		2	2								
H5522	002	0	1	04	01	H5522_002_0	7	7	30% Coinsurance	10		000000000000000000100000	2		2			1	100.00	2	1			30	30				
H5522	002	0	1	04	01	H5522_002_0	7	1	0% Coinsurance OON	01	000001000000000000000000000000000000		2		2			2		2	1			0	0				
H5522	002	0	1	04	01	H5522_002_0	7	9	0%-20%	01	000000000000000000000000000010000000		2		2			2		2	1			0	20				
H5522	002	0	1	04	01	H5522_002_0	7	8	50% Dental Coinsurance (Non-Medicare)	10		000000000000000000010000	2		2			1	100.00	2	1			50	50				
H5522	002	0	1	04	01	H5522_002_0	7	6	50% Coinsurance	10		000000000000000000000001	2		2			2		2	1			50	50				
H5522	004	0	1	04	01	H5522_004_0	5	6	0%-40%	01	000000000000000000000000000010000000		2		2			2		2	1			0	40				
H5522	004	0	1	04	01	H5522_004_0	5	5	Ambulance OON	01	000000000000000000000001000000000000		2		1	175.00	175.00	2		2	2								
H5522	004	0	1	04	01	H5522_004_0	5	4	GYM OON Monthly Copay	10		000000000000000010000000	2		1	50.00	50.00	2		2	2								
H5522	004	0	1	04	01	H5522_004_0	5	3	45% Coinsurance OON	01	000010000010010000000100000000000000		2		2			2		2	1			45	45				
H5522	004	0	1	04	01	H5522_004_0	5	1	0% Coinsurance OON	01	000001000000000000000000000000000000		2		2			2		2	1			0	0				
H5522	004	0	1	04	01	H5522_004_0	5	2	40% Coinsurance OON	11	011100111101101111111010111101111111	000001100001000000001010	2		2			2		2	1			40	40				
H5522	005	0	1	04	01	H5522_005_0	5	2	20% Coinsurance OON	11	011100111101101111111010111101111111	000001100001000000001010	2		2			2		2	1			20	20				
H5522	005	0	1	04	01	H5522_005_0	5	3	45% Coinsurance OON	01	000010000010010000000100000000000000		2		2			2		2	1			45	45				
H5522	005	0	1	04	01	H5522_005_0	5	4	GYM OON Monthly Copay	10		000000000000000010000000	2		1	50.00	50.00	2		2	2								
H5522	005	0	1	04	01	H5522_005_0	5	5	Ambulance OON	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H5522	005	0	1	04	01	H5522_005_0	5	6	0%-20%	01	000000000000000000000000000010000000		2		2			2		2	1			0	20				
H5522	005	0	1	04	01	H5522_005_0	5	1	0% Coinsurance OON	01	000001000000000000000000000000000000		2		2			2		2	1			0	0				
H5522	008	0	1	04	01	H5522_008_0	7	3	45% Coinsurance OON	01	000010000010010000000100000000000000		2		2			2		2	1			45	45				
H5522	008	0	1	04	01	H5522_008_0	7	5	0%-35%	01	000000000000000000000000000010000000		2		2			2		2	1			0	35				
H5522	008	0	1	04	01	H5522_008_0	7	4	GYM OON Monthly Copay	10		000000000000000010000000	2		1	50.00	50.00	2		2	2								
H5522	008	0	1	04	01	H5522_008_0	7	2	35%  Coinsurance OON	11	011100111101101111111010111101111111	000001100001000000001010	2		2			2		2	1			35	35				
H5522	008	0	1	04	01	H5522_008_0	7	1	0% Coinsurance OON	01	000001000000000000000001000000000000		2		2			2		2	1			0	0				
H5522	009	0	1	04	01	H5522_009_0	5	1	0% Coinsurance OON	01	000001000000000000000001000000000000		2		2			2		2	1			0	0				
H5522	009	0	1	04	01	H5522_009_0	5	5	0%-35%	01	000000000000000000000000000010000000		2		2			2		2	1			0	35				
H5522	009	0	1	04	01	H5522_009_0	5	4	GYM OON Monthly Copay	10		000000000000000010000000	2		1	50.00	50.00	2		2	2								
H5522	009	0	1	04	01	H5522_009_0	5	3	45% Coinsurance OON	01	000010000010010000000100000000000000		2		2			2		2	1			45	45				
H5522	009	0	1	04	01	H5522_009_0	5	2	35%  Coinsurance OON	11	011100111101101111111010111101111111	000001100001000000001010	2		2			2		2	1			35	35				
H5522	013	0	1	04	01	H5522_013_0	5	4	GYM OON Monthly Copay	10		000000000000000010000000	2		1	50.00	50.00	2		2	2								
H5522	013	0	1	04	01	H5522_013_0	5	6	0%- 20%	01	000000000000000000000000000010000000		2		2			2		2	1			0	20				
H5522	013	0	1	04	01	H5522_013_0	5	5	Ambulance OON	01	000000000000000000000001000000000000		2		1	125.00	125.00	2		2	2								
H5522	013	0	1	04	01	H5522_013_0	5	3	45% Coinsurance OON	01	000010000010010000000100000000000000		2		2			2		2	1			45	45				
H5522	013	0	1	04	01	H5522_013_0	5	2	20% Coinsurance OON	11	011100111101101111111010111101111111	000001100001000000001010	2		2			2		2	1			20	20				
H5522	013	0	1	04	01	H5522_013_0	5	1	0% Coinsurance OON	01	000001000000000000000000000000000000		2		2			2		2	1			0	0				
H5522	014	0	1	04	01	H5522_014_0	5	7	Comprehensive Dental	10		000000000000000000010000	2		2			1	100.00	2	1			50	50				
H5522	014	0	1	04	01	H5522_014_0	5	1	0% Coinsurance OON	01	000001000000000000000000000000000000		2		2			2		2	1			0	0				
H5522	014	0	1	04	01	H5522_014_0	5	2	20% Coinsurance OON	11	011100111101101111111010111101111111	000001100001000000001010	2		2			2		2	1			20	20				
H5522	014	0	1	04	01	H5522_014_0	5	6	30% Coinsurance	10		000000000000000000100000	2		2			1	100.00	2	1			30	30				
H5522	014	0	1	04	01	H5522_014_0	5	9	0%- 20%	01	000000000000000000000000000010000000		2		2			2		2	1			0	20				
H5522	014	0	1	04	01	H5522_014_0	5	5	Ambulance OON	01	000000000000000000000001000000000000		2		1	75.00	75.00	2		2	2								
H5522	014	0	1	04	01	H5522_014_0	5	4	GYM OON Monthly Copay	10		000000000000000010000000	2		1	50.00	50.00	2		2	2								
H5522	014	0	1	04	01	H5522_014_0	5	3	45% Coinsurance OON	01	000010000010010000000100000000000000		2		2			2		2	1			45	45				
H5522	014	0	1	04	01	H5522_014_0	5	8	50% Coinsurance	10		000000000000000000000001	2		2			2		2	1			50	50				
H5522	015	0	1	04	01	H5522_015_0	5	9	0%- 20%	01	000000000000000000000000000010000000		2		2			2		2	1			0	20				
H5522	015	0	1	04	01	H5522_015_0	5	2	20% Coinsurance OON	11	011100111101101111111010111101111111	000001100001000000001010	2		2			2		2	1			20	20				
H5522	015	0	1	04	01	H5522_015_0	5	7	Comprehensive Dental	10		000000000000000000010000	2		2			1	100.00	2	1			50	50				
H5522	015	0	1	04	01	H5522_015_0	5	8	50% Coinsurance	10		000000000000000000000001	2		2			2		2	1			50	50				
H5522	015	0	1	04	01	H5522_015_0	5	3	45% Coinsurance OON	01	000010000010010000000100000000000000		2		2			2		2	1			45	45				
H5522	015	0	1	04	01	H5522_015_0	5	4	GYM OON Monthly Copay	10		000000000000000010000000	2		1	50.00	50.00	2		2	2								
H5522	015	0	1	04	01	H5522_015_0	5	5	Ambulance OON	01	000000000000000000000001000000000000		2		1	175.00	175.00	2		2	2								
H5522	015	0	1	04	01	H5522_015_0	5	6	30% Coinsurance	10		000000000000000000100000	2		2			1	100.00	2	1			30	30				
H5522	015	0	1	04	01	H5522_015_0	5	1	0% Coinsurance OON	01	000001000000000000000000000000000000		2		2			2		2	1			0	0				
H5522	802	0	1	04	01	H5522_802_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H5522	802	0	1	04	01	H5522_802_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H5522	802	0	1	04	01	H5522_802_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H5522	803	0	1	04	01	H5522_803_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H5522	803	0	1	04	01	H5522_803_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H5522	803	0	1	04	01	H5522_803_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H5522	805	0	1	04	01	H5522_805_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H5522	805	0	1	04	01	H5522_805_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H5522	805	0	1	04	01	H5522_805_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H5525	004	0	1	04	01	H5525_004_0	4	1		10		000000000000000000000010	2		1	35.00	35.00	2		2	2								
H5525	004	0	1	04	01	H5525_004_0	4	2		11	011111111111111111111100111001111101	000001000000000100000000	2		2			2		2	1			30	30				
H5525	004	0	1	04	01	H5525_004_0	4	3		01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H5525	004	0	1	04	01	H5525_004_0	4	4		01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H5525	004	0	1	04	01	H5525_004_0	4	5		11	000000000000000000000010000000000010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H5525	004	0	1	04	01	H5525_004_0	4	6		10		000000000110000010110000	2		2			2		2	1			50	50				
H5525	004	0	1	04	01	H5525_004_0	4	7		01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H5525	005	0	1	04	01	H5525_005_0	7	1		11	011111111111111111111100111001111101	000000000000000100000000	2		2			2		2	1			20	20				
H5525	005	0	1	04	01	H5525_005_0	7	2		01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H5525	005	0	1	04	01	H5525_005_0	7	5		10		000000000110000010000000	2		2			2		2	1			50	50				
H5525	005	0	1	04	01	H5525_005_0	7	4		11	000000000000000000000010000000000010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H5525	005	0	1	04	01	H5525_005_0	7	3		01	000000000000000000000000000110000000		2		2			2		2	1			0	20				
H5526	003	0	1	04	01	H5526_003_0	16	1	Outpatient/ASC Services	01	000000000000000000011000000000000000		2		2			2		2	1			20	20				
H5526	003	0	1	04	01	H5526_003_0	16	9	Part B Drugs	01	000000000000000000000000000000010000		2		1	0.00	75.00	2		2	2								
H5526	003	0	1	04	01	H5526_003_0	16	2	Ambulance	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H5526	003	0	1	04	01	H5526_003_0	16	10	ESRD and Enhanced Disease Management	11	000000000000000000000000000100000000	000000000001000000000000	2		2			2		2	2								
H5526	003	0	1	04	01	H5526_003_0	16	6	DME/Prosthetics	01	000000000000000000000000111000000000		2		2			2		2	1			50	50				
H5526	003	0	1	04	01	H5526_003_0	16	7	Primary Care/Home Health	01	000001100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
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H5526	003	0	1	04	01	H5526_003_0	16	3	Mental Health/Subs Abuse/Psychiatric Svc	01	000010000010010000000100000000000000		2		2			2		2	1			50	50				
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H5526	004	0	1	04	01	H5526_004_0	15	4	Home Health	01	000001000000000000000000000000000000		2		1	30.00	30.00	2		2	2								
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H5526	004	0	1	04	01	H5526_004_0	15	11	ESRD and Enhanced Disease Management	11	000000000000000000000000000100000000	000000000001000000000000	2		2			2		2	2								
H5526	004	0	1	04	01	H5526_004_0	15	12	Transportation	10		000000010000000000000000	2		2			2		2	1			50	50				
H5526	004	0	1	04	01	H5526_004_0	15	13	Vision	11	000000000000000000000000000000000010	000000000000000000001000	2		2			2		2	1			45	45				
H5526	004	0	1	04	01	H5526_004_0	15	7	DME/Prosthetics	01	000000000000000000000000111000000000		2		2			2		2	1			35	35				
H5526	013	0	1	04	01	H5526_013_0	14	9	Diagnostic Radiological Services	01	000000000000000010000000000000000000		2		1	75.00	75.00	2		2	2								
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H5526	013	0	1	04	01	H5526_013_0	14	6	Health Education and Wellness	10		000000000000000010000000	2		1	0.00	50.00	2		2	2								
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H5526	013	0	1	04	01	H5526_013_0	14	11	ESRD and Enhanced Disease Management	11	000000000000000000000000000100000000	000000000001000000000000	2		2			2		2	2								
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H5526	013	0	1	04	01	H5526_013_0	14	1	Outpatient/ASC Services	01	000000000000000000011000000000000000		2		2			2		2	1			20	20				
H5526	013	0	1	04	01	H5526_013_0	14	12	Transportation and Vision	10		000000010000000000001000	2		2			2		2	1			55	55				
H5526	806	0	1	04	01	H5526_806_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H5526	806	0	1	04	01	H5526_806_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H5526	806	0	1	04	01	H5526_806_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H5526	808	0	1	04	01	H5526_808_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H5526	808	0	1	04	01	H5526_808_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H5526	808	0	1	04	01	H5526_808_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H5526	810	0	1	04	01	H5526_810_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
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H5526	810	0	1	04	01	H5526_810_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H5528	001	0	1	04	01	H5528_001_0	8	6	30% Cost Sharing	01	000000000000000000000000111000000000		2		2			2		2	1			30	30				
H5528	001	0	1	04	01	H5528_001_0	8	5	$75 Cost Sharing	01	000000000000000000000001000000000000		2		1	75.00	75.00	2		2	2								
H5528	001	0	1	04	01	H5528_001_0	8	4	50% Cost Sharing	11	011100001000001000000000000000010010	000000000000000000101100	2		2			2		2	1			50	50				
H5528	001	0	1	04	01	H5528_001_0	8	3	$40 Cost Sharing	11	000000010001000000000000000000000000	000001000000000000000000	2		1	40.00	40.00	2		2	2								
H5528	001	0	1	04	01	H5528_001_0	8	2	$0 Cost Sharing	01	000001000000000000000000000101000000		2		1	0.00	0.00	2		2	2								
H5528	001	0	1	04	01	H5528_001_0	8	1	25%Cost Sharing w/o sep ofc visit copay	11	000010100110110110111110000010101101	000000100001000000000000	2		2			2		2	1			25	25				
H5528	001	0	1	04	01	H5528_001_0	8	7	25%Cost Sharing w/ sep ofc visit copay	01	000000000000000001000000000000000000		2		2			2		1	1	1	25	25	25	25	2		
H5528	002	0	1	04	01	H5528_002_0	12	7	25%Cost Sharing w/ sep ofc visit copay	01	000000000000000001000000000000000000		2		2			2		2	1			25	25				
H5528	002	0	1	04	01	H5528_002_0	12	6	30% Cost Sharing	01	000000000000000000000000111000000000		2		2			2		2	1			30	30				
H5528	002	0	1	04	01	H5528_002_0	12	5	$125 Cost Sharing	01	000000000000000000000001000000000000		2		1	125.00	125.00	2		2	2								
H5528	002	0	1	04	01	H5528_002_0	12	3	$40 Cost Sharing	11	000000010001000000000000000000000000	000001000000000000000000	2		1	40.00	40.00	2		2	2								
H5528	002	0	1	04	01	H5528_002_0	12	2	$0 Cost Sharing	01	000001000000000000000000000101000000		2		1	0.00	0.00	2		2	2								
H5528	002	0	1	04	01	H5528_002_0	12	1	25%Cost Sharing w/o sep ofc visit copay	11	000010100110110110111110000010101001	000000100001000000001000	2		2			2		2	1			25	25				
H5528	002	0	1	04	01	H5528_002_0	12	4	50% Cost Sharing	11	011100001000001000000000000000010110	000000000000000000100100	2		2			2		2	1			50	50				
H5528	003	0	1	04	01	H5528_003_0	12	7	25%Cost Sharing w/ sep ofc visit copay	01	000000000000000001000000000000000000		2		2			2		2	1			25	25				
H5528	003	0	1	04	01	H5528_003_0	12	1	25%Cost Sharing w/o sep ofc visit copay	11	000010100110110110111110000010101101	000000100001000000001000	2		2			2		2	1			25	25				
H5528	003	0	1	04	01	H5528_003_0	12	2	$0 Cost Sharing	01	000001000000000000000000000101000000		2		1	0.00	0.00	2		2	2								
H5528	003	0	1	04	01	H5528_003_0	12	3	$40 Cost Sharing	11	000000010001000000000000000000000000	000001000000000000000000	2		1	40.00	40.00	2		2	2								
H5528	003	0	1	04	01	H5528_003_0	12	4	50% Cost Sharing	11	011100001000001000000000000000010110	000000000000000000100000	2		2			2		2	1			50	50				
H5528	003	0	1	04	01	H5528_003_0	12	5	$75 Cost Sharing	01	000000000000000000000001000000000000		2		1	75.00	75.00	2		2	2								
H5528	003	0	1	04	01	H5528_003_0	12	6	30% Cost Sharing	01	000000000000000000000000111000000000		2		2			2		2	1			30	30				
H5528	004	0	1	04	01	H5528_004_0	10	1	25%Cost Sharing w/o sep ofc visit copay	11	000010100110110110111110000010101101	000000100001000000000000	2		2			2		2	1			25	25				
H5528	004	0	1	04	01	H5528_004_0	10	2	$0 Cost Sharing	01	000001000000000000000000000101000000		2		1	0.00	0.00	2		2	2								
H5528	004	0	1	04	01	H5528_004_0	10	3	$40 Cost Sharing	11	000000010001000000000000000000000000	000001000000000000000000	2		1	40.00	40.00	2		2	2								
H5528	004	0	1	04	01	H5528_004_0	10	4	50% Cost Sharing	11	011100001000001000000000000000010010	000000000000000000101100	2		2			2		2	1			50	50				
H5528	004	0	1	04	01	H5528_004_0	10	5	$75 Cost Sharing	01	000000000000000000000001000000000000		2		1	75.00	75.00	2		2	2								
H5528	004	0	1	04	01	H5528_004_0	10	6	30% Cost Sharing	01	000000000000000000000000111000000000		2		2			2		2	1			30	30				
H5528	004	0	1	04	01	H5528_004_0	10	7	25%Cost Sharing w/ sep ofc visit copay	01	000000000000000001000000000000000000		2		2			2		2	1			25	25				
H5528	005	0	1	04	01	H5528_005_0	16	6	30% Cost Sharing	01	000000000000000000000000111000000000		2		2			2		2	1			30	30				
H5528	005	0	1	04	01	H5528_005_0	16	7	25%Cost Sharing w/ sep ofc visit copay	01	000000000000000001000000000000000000		2		2			2		2	1			25	25				
H5528	005	0	1	04	01	H5528_005_0	16	5	$125 Cost Sharing	01	000000000000000000000001000000000000		2		1	125.00	125.00	2		2	2								
H5528	005	0	1	04	01	H5528_005_0	16	4	50% Cost Sharing	11	011100001000001000000000000000010110	000000000000000000100000	2		2			2		2	1			50	50				
H5528	005	0	1	04	01	H5528_005_0	16	3	$40 Cost Sharing	11	000000010001000000000000000000000000	000001000000000000000000	2		1	40.00	40.00	2		2	2								
H5528	005	0	1	04	01	H5528_005_0	16	2	$0 Cost Sharing	01	000001000000000000000000000101000000		2		1	0.00	0.00	2		2	2								
H5528	005	0	1	04	01	H5528_005_0	16	1	25%Cost Sharing w/o sep ofc visit copay	11	000010100110110110111110000010101101	000000100001000000001000	2		2			2		2	1			25	25				
H5528	008	0	1	04	01	H5528_008_0	13	3	$40 Cost Sharing	11	000000010001000000000000000000000000	000001000000000000000000	2		1	40.00	40.00	2		2	2								
H5528	008	0	1	04	01	H5528_008_0	13	4	50% Cost Sharing	11	011100001000001000000000000000010110	000000000000000000100000	2		2			2		2	1			50	50				
H5528	008	0	1	04	01	H5528_008_0	13	5	$75 Cost Sharing	01	000000000000000000000001000000000000		2		1	75.00	75.00	2		2	2								
H5528	008	0	1	04	01	H5528_008_0	13	6	30% Cost Sharing	01	000000000000000000000000111000000000		2		2			2		2	1			30	30				
H5528	008	0	1	04	01	H5528_008_0	13	7	25%Cost Sharing w/ sep ofc visit copay	01	000000000000000001000000000000000000		2		2			2		2	1			25	25				
H5528	008	0	1	04	01	H5528_008_0	13	1	25%Cost Sharing w/o sep ofc visit copay	11	000010100110110110111110000010101101	000000100001000000001000	2		2			2		2	1			25	25				
H5528	008	0	1	04	01	H5528_008_0	13	2	$0 Cost Sharing	01	000001000000000000000000000101000000		2		1	0.00	0.00	2		2	2								
H5528	009	0	1	04	01	H5528_009_0	9	7	25%Cost Sharing w/ sep ofc visit copay	01	000000000000000001000000000000000000		2		2			2		1	1	1	25	25	25	25	2		
H5528	009	0	1	04	01	H5528_009_0	9	6	30% Cost Sharing	01	000000000000000000000000111000000000		2		2			2		2	1			30	30				
H5528	009	0	1	04	01	H5528_009_0	9	5	$75 Cost Sharing	01	000000000000000000000001000000000000		2		1	75.00	75.00	2		2	2								
H5528	009	0	1	04	01	H5528_009_0	9	4	50% Cost Sharing	11	011100001000001000000000000000010010	000000000000000000101100	2		2			2		2	1			50	50				
H5528	009	0	1	04	01	H5528_009_0	9	3	$40 Cost Sharing	11	000000010001000000000000000000000000	000001000000000000000000	2		1	40.00	40.00	2		2	2								
H5528	009	0	1	04	01	H5528_009_0	9	2	$0 Cost Sharing	01	000001000000000000000000000101000000		2		1	0.00	0.00	2		2	2								
H5528	009	0	1	04	01	H5528_009_0	9	1	25%Cost Sharing w/o sep ofc visit copay	11	000010100110110110111110000010101101	000000100001000000000000	2		2			2		2	1			25	25				
H5528	010	0	1	04	01	H5528_010_0	14	1	25%Cost Sharing w/o sep ofc visit copay	11	000010100110110110111110000010101001	000000100001000000001000	2		2			2		2	1			25	25				
H5528	010	0	1	04	01	H5528_010_0	14	2	$0 Cost Sharing	01	000001000000000000000000000101000000		2		1	0.00	0.00	2		2	2								
H5528	010	0	1	04	01	H5528_010_0	14	7	25%Cost Sharing w/ sep ofc visit copay	01	000000000000000001000000000000000000		2		2			2		2	1			25	25				
H5528	010	0	1	04	01	H5528_010_0	14	6	30% Cost Sharing	01	000000000000000000000000111000000000		2		2			2		2	1			30	30				
H5528	010	0	1	04	01	H5528_010_0	14	5	$125 Cost Sharing	01	000000000000000000000001000000000000		2		1	125.00	125.00	2		2	2								
H5528	010	0	1	04	01	H5528_010_0	14	4	50% Cost Sharing	11	011100001000001000000000000000010110	000000000000000000100100	2		2			2		2	1			50	50				
H5528	010	0	1	04	01	H5528_010_0	14	3	$40 Cost Sharing	11	000000010001000000000000000000000000	000001000000000000000000	2		1	40.00	40.00	2		2	2								
H5528	011	0	1	04	01	H5528_011_0	13	3	$40 Cost Sharing	11	000000010001000000000000000000000000	000001000000000000000000	2		1	40.00	40.00	2		2	2								
H5528	011	0	1	04	01	H5528_011_0	13	4	50% Cost Sharing	11	011100001000001000000000000000010110	000000000000000000100000	2		2			2		2	1			50	50				
H5528	011	0	1	04	01	H5528_011_0	13	6	30% Cost Sharing	01	000000000000000000000000111000000000		2		2			2		2	1			30	30				
H5528	011	0	1	04	01	H5528_011_0	13	5	$75 Cost Sharing	01	000000000000000000000001000000000000		2		1	75.00	75.00	2		2	2								
H5528	011	0	1	04	01	H5528_011_0	13	7	25%Cost Sharing w/ sep ofc visit copay	01	000000000000000001000000000000000000		2		2			2		2	1			25	25				
H5528	011	0	1	04	01	H5528_011_0	13	2	$0 Cost Sharing	01	000001000000000000000000000101000000		2		1	0.00	0.00	2		2	2								
H5528	011	0	1	04	01	H5528_011_0	13	1	25%Cost Sharing w/o sep ofc visit copay	11	000010100110110110111110000010101101	000000100001000000001000	2		2			2		2	1			25	25				
H5528	018	0	1	04	01	H5528_018_0	13	2	OTC Benefit	10		000000000100000000000000	2		1	660.00	660.00	2		2	2								
H5528	018	0	1	04	01	H5528_018_0	13	1	$0 Cost Sharing	11	011111111111111111111111111111111111	000001100001000000100100	2		1	0.00	0.00	2		2	2								
H5528	019	0	1	04	01	H5528_019_0	12	2	$0 Cost Sharing	01	000001000000000000000001000101000000		2		1	0.00	0.00	2		2	2								
H5528	019	0	1	04	01	H5528_019_0	12	3	35% Cost Sharing w/ sep ofc visit copay	01	000000000000000001000000000000000000		2		2			2		1	1	1	35	35	35	35	2		
H5528	019	0	1	04	01	H5528_019_0	12	1	35% Cost Sharing	11	011110111111111110111110111010111111	000001100001000000101110	2		2			2		2	1			35	35				
H5528	020	0	1	04	01	H5528_020_0	13	3	35% Cost Sharing w/ sep ofc visit copay	01	000000000000000001000000000000000000		2		2			2		1	1	1	35	35	35	35	2		
H5528	020	0	1	04	01	H5528_020_0	13	2	$0 Cost Sharing	01	000001000000000000000001000101000000		2		1	0.00	0.00	2		2	2								
H5528	020	0	1	04	01	H5528_020_0	13	1	35% Cost Sharing	11	011110111111111110111110111010111111	000001100001000000101110	2		2			2		2	1			35	35				
H5528	021	0	1	04	01	H5528_021_0	13	3	35% Cost Sharing w/ sep ofc visit copay	01	000000000000000001000000000000000000		2		2			2		1	1	1	35	35	35	35	2		
H5528	021	0	1	04	01	H5528_021_0	13	2	$0 Cost Sharing	01	000001000000000000000001000101000000		2		1	0.00	0.00	2		2	2								
H5528	021	0	1	04	01	H5528_021_0	13	1	35% Cost Sharing	11	011110111111111110111110111010111111	000001100001000000101110	2		2			2		2	1			35	35				
H5528	804	0	1	04	01	H5528_804_0	8	1	20% Coinsurance	01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H5528	804	0	1	04	01	H5528_804_0	8	2	40% Coinsurance	01	000000000010010000000000000000000000		2		2			2		2	1			40	40				
H5528	804	0	1	04	01	H5528_804_0	8	3	0% Coinsurance	01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H5528	807	0	1	04	01	H5528_807_0	8	3	0% Coinsurance	01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H5528	807	0	1	04	01	H5528_807_0	8	2	40% Coinsurance	01	000000000010010000000000000000000000		2		2			2		2	1			40	40				
H5528	807	0	1	04	01	H5528_807_0	8	1	20% Coinsurance	01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H5529	001	0	1	04	01	H5529_001_0	12	1	20%	11	000000000000000001000000000100010000	000000000000000000100000	2		2			2		2	1			20	20				
H5529	001	0	1	04	01	H5529_001_0	12	10	$0	11	011101000000000000000010000011101010	000000100000000010001100	2		1	0.00	0.00	2		2	2								
H5529	001	0	1	04	01	H5529_001_0	12	11	$0 - $40	01	000000000000000000000000000000000100		2		1	0.00	40.00	2		2	2								
H5529	001	0	1	04	01	H5529_001_0	12	2	35%	01	000000000000000000000000111000000000		2		2			2		2	1			35	35				
H5529	001	0	1	04	01	H5529_001_0	12	3	$0 - $20 - 30%	01	000000000000000100000000000000000000		2		1	0.00	20.00	2		2	1			30	30				
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H5529	004	0	1	04	01	H5529_004_0	12	5	$25 -$40 - 30%	01	000000000000000000010000000000000000		2		1	25.00	40.00	2		2	1			30	30				
H5529	004	0	1	04	01	H5529_004_0	12	4	30%	01	000000000000000000001000000000000000		2		2			2		2	1			30	30				
H5529	004	0	1	04	01	H5529_004_0	12	3	$0 -$20 - 30%	01	000000000000000100000000000000000000		2		1	0.00	20.00	2		2	1			30	30				
H5529	004	0	1	04	01	H5529_004_0	12	2	30%	01	000000000000000010100000111000000000		2		2			2		2	1			30	30				
H5529	004	0	1	04	01	H5529_004_0	12	11	$0 - $40	01	000000000000000000000000000000000100		2		1	0.00	40.00	2		2	2								
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H5529	005	0	1	04	01	H5529_005_0	12	3	$0 -$20 - 30%	01	000000000000000100000000000000000000		2		1	0.00	20.00	2		2	1			30	30				
H5529	005	0	1	04	01	H5529_005_0	12	10	$0	11	011101000000000000000010000011101010	000000100000000010000000	2		1	0.00	0.00	2		2	2								
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H5529	005	0	1	04	01	H5529_005_0	12	9	$150	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
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H5529	005	0	1	04	01	H5529_005_0	12	5	$30 -$45- 30%	01	000000000000000000010000000000000000		2		1	30.00	45.00	2		2	1			30	30				
H5529	005	0	1	04	01	H5529_005_0	12	4	30%	01	000000000000000000001000000000000000		2		2			2		2	1			30	30				
H5529	804	0	1	04	01	H5529_804_0	7	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
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H5529	804	0	1	04	01	H5529_804_0	7	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
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H5529	805	0	1	04	01	H5529_805_0	5	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H5529	805	0	1	04	01	H5529_805_0	5	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H5529	806	0	1	04	01	H5529_806_0	5	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H5529	806	0	1	04	01	H5529_806_0	5	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H5529	806	0	1	04	01	H5529_806_0	5	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H5530	001	0	1	04	01	H5530_001_0	12	1	20%	01	000000000000000001000000000100010000		2		2			2		2	1			20	20				
H5530	001	0	1	04	01	H5530_001_0	12	10	$0	11	011101000000000000000010000011101010	000000100000000010000000	2		1	0.00	0.00	2		2	2								
H5530	001	0	1	04	01	H5530_001_0	12	7	$45	11	000000001101001000000000000000000001	000000000000000000000010	2		1	45.00	45.00	2		2	2								
H5530	001	0	1	04	01	H5530_001_0	12	8	$50	01	000010000010010000000100000000000000		2		1	50.00	50.00	2		2	2								
H5530	001	0	1	04	01	H5530_001_0	12	11	$0 - $45	01	000000000000000000000000000000000100		2		1	0.00	45.00	2		2	2								
H5530	001	0	1	04	01	H5530_001_0	12	6	$30	01	000000110000100000000000000000000000		2		1	30.00	30.00	2		2	2								
H5530	001	0	1	04	01	H5530_001_0	12	2	30%	01	000000000000000010100000111000000000		2		2			2		2	1			30	30				
H5530	001	0	1	04	01	H5530_001_0	12	3	$0 - $20 - 30%	01	000000000000000100000000000000000000		2		1	0.00	20.00	2		2	1			30	30				
H5530	001	0	1	04	01	H5530_001_0	12	4	30%	01	000000000000000000001000000000000000		2		2			2		2	1			30	30				
H5530	001	0	1	04	01	H5530_001_0	12	5	$30 - $45 - 30%	01	000000000000000000010000000000000000		2		1	30.00	45.00	2		2	1			30	30				
H5530	001	0	1	04	01	H5530_001_0	12	9	$150	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H5530	004	0	1	04	01	H5530_004_0	12	9	$150	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
H5530	004	0	1	04	01	H5530_004_0	12	8	$50	01	000010000010010000000100000000000000		2		1	50.00	50.00	2		2	2								
H5530	004	0	1	04	01	H5530_004_0	12	7	$35	11	000000011101001000000000000000000001	000000000000000000000010	2		1	35.00	35.00	2		2	2								
H5530	004	0	1	04	01	H5530_004_0	12	5	$20 - $35 - 30%	01	000000000000000000010000000000000000		2		1	20.00	35.00	2		2	1			30	30				
H5530	004	0	1	04	01	H5530_004_0	12	4	30%	01	000000000000000000001000000000000000		2		2			2		2	1			30	30				
H5530	004	0	1	04	01	H5530_004_0	12	3	$0 - $20 - 30%	01	000000000000000100000000000000000000		2		1	0.00	20.00	2		2	1			30	30				
H5530	004	0	1	04	01	H5530_004_0	12	2	30%	01	000000000000000010100000111000000000		2		2			2		2	1			30	30				
H5530	004	0	1	04	01	H5530_004_0	12	11	$0 -$35	01	000000000000000000000000000000000100		2		1	0.00	35.00	2		2	2								
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H5530	004	0	1	04	01	H5530_004_0	12	1	20%	11	000000000000000001000000000100010000	000000000000000000100000	2		2			2		2	1			20	20				
H5530	004	0	1	04	01	H5530_004_0	12	6	$20	01	000000100000100000000000000000000000		2		1	20.00	20.00	2		2	2								
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H5530	804	0	1	04	01	H5530_804_0	8	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H5530	804	0	1	04	01	H5530_804_0	8	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
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H5530	805	0	1	04	01	H5530_805_0	8	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H5530	805	0	1	04	01	H5530_805_0	8	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H5530	806	0	1	04	01	H5530_806_0	8	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H5530	806	0	1	04	01	H5530_806_0	8	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
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H5532	001	0	1	04	01	H5532_001_0	7	5	Group 5	01	000000000000000000100000000000000000		2		1	21.00	21.00	2		2	2								
H5532	001	0	1	04	01	H5532_001_0	7	6	Group 6	01	000010000000000000000000000000000000		2		1	75.00	75.00	2		2	2								
H5532	001	0	1	04	01	H5532_001_0	7	7	Group 7	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H5532	001	0	1	04	01	H5532_001_0	7	8	Group 8	01	000000000010010000000100000000000000		2		1	35.00	45.00	2		2	2								
H5532	001	0	1	04	01	H5532_001_0	7	9	Group 9	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H5532	001	0	1	04	01	H5532_001_0	7	1	Group 1	11	000000100000000000000000000000000000	000000000000000000100000	2		1	40.00	40.00	2		2	2								
H5532	001	0	1	04	01	H5532_001_0	7	10	Group 10	11	000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2	2								
H5532	001	0	1	04	01	H5532_001_0	7	11	Group 11	01	000001000000000000000000100000010000		2		2			2		2	1			50	50				
H5532	001	0	1	04	01	H5532_001_0	7	12	Group 12	01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H5532	001	0	1	04	01	H5532_001_0	7	13	Group 13	01	000000000000100000000000000000000000		2		1	40.00	45.00	2		2	2								
H5532	001	0	1	04	01	H5532_001_0	7	14	Group 14	10		000000000000000000000001	2		1	110.00	160.00	2		2	2								
H5532	001	0	1	04	01	H5532_001_0	7	2	Group 2	11	011100011101001000000000000000001101	000001000000000000001010	2		1	45.00	45.00	2		2	2								
H5532	001	0	1	04	01	H5532_001_0	7	3	Group 3	11	000000000000000011011000011001100010	000000000001000100000000	2		2			2		2	1			30	30				
H5532	001	0	1	04	01	H5532_001_0	7	4	Group 4	01	000000000000000100000000000000000000		2		1	13.00	13.00	2		2	1			30	30				
H5533	003	0	1	04	01	H5533_003_0	9	7	50% OON	01	000000000000000000000000110000010000		2		2			2		2	1			50	50				
H5533	003	0	1	04	01	H5533_003_0	9	3	$30 OON Copay	11	000000110000000000000000000000000000	000010000000000000000000	2		1	30.00	30.00	2		2	2								
H5533	003	0	1	04	01	H5533_003_0	9	2	30% coins - PCP/Spec Copay could apply	01	000000000000000111100000000000000000		2		2			2		1	1	2		30	30		1	30.00	50.00
H5533	003	0	1	04	01	H5533_003_0	9	1	30% Coinsurance	11	011111001000001000011011001111100010	000000100000000100000000	2		2			2		2	1			30	30				
H5533	003	0	1	04	01	H5533_003_0	9	5	OON Routine Vision	10		000000000000000000001100	2		1	0.00	0.00	2		2	2								
H5533	003	0	1	04	01	H5533_003_0	9	6	50% with $250 annual max	10		000000000000000010000000	1	250.00	2			2		2	1			50	50				
H5533	003	0	1	04	01	H5533_003_0	9	4	$50 OON Copay	11	000000000111110000000100000000001101	000001000000000000000000	2		1	50.00	50.00	2		2	2								
H5533	004	0	1	04	01	H5533_004_0	11	4	30% OON - PCP/Spec Copay could apply	01	000000000000000111100000000000000000		2		2			2		1	1	2		30	30		1	30.00	50.00
H5533	004	0	1	04	01	H5533_004_0	11	3	30% OON Coinsurance	11	011111001000001000011011000111100010	000000100000000100000000	2		2			2		2	1			30	30				
H5533	004	0	1	04	01	H5533_004_0	11	2	$50 OON Copay	11	000000000111110000000100000000001101	000001000000000000000010	2		1	50.00	50.00	2		2	2								
H5533	004	0	1	04	01	H5533_004_0	11	7	50% OON	11	000000000000000000000000111000010000	000000000000000000000001	2		2			2		2	1			50	50				
H5533	004	0	1	04	01	H5533_004_0	11	5	50% ONN with $250 Max	10		000000000000000010000000	1	250.00	2			2		2	1			50	50				
H5533	004	0	1	04	01	H5533_004_0	11	1	$30 OON Copay	11	000000110000000000000000000000000000	000010000000000000000000	2		1	30.00	30.00	2		2	2								
H5533	004	0	1	04	01	H5533_004_0	11	6	Zero OON Cost Sharing	10		000000000000000000001100	2		1	0.00	0.00	2		2	2								
H5533	801	0	1	04	01	H5533_801_0	5	1	20% Coinsurance	11	011111111111111000011111000111101111	000011100000000100000010	2		2			2		2	1			20	20				
H5533	801	0	1	04	01	H5533_801_0	5	5	20% Coins with PCP/Spec Copay	01	000000000000000111100000000000000000		2		2			2		1	1	1	20	20	20	20	2		
H5533	801	0	1	04	01	H5533_801_0	5	4	$0 OON Cost Sharing	10		000000000000000000001100	2		1	0.00	0.00	2		2	2								
H5533	801	0	1	04	01	H5533_801_0	5	3	50% with $250 Annual allowance	10		000000000000000010000000	1	250.00	2			2		2	1			50	50				
H5533	801	0	1	04	01	H5533_801_0	5	2	50% Coinsurance	11	000000000000000000000000111000010000	000000000000000000110001	2		2			2		2	1			50	50				
H5533	802	0	1	04	01	H5533_802_0	6	5	20% Coins with PCP/Spec Copay	01	000000000000000111100000000000000000		2		2			2		1	1	1	20	20	20	20	2		
H5533	802	0	1	04	01	H5533_802_0	6	4	$0 OON Cost Sharing	10		000000000000000000001100	2		1	0.00	0.00	2		2	2								
H5533	802	0	1	04	01	H5533_802_0	6	3	50% with $250 Annual allowance	10		000000000000000010000000	1	250.00	2			2		2	1			50	50				
H5533	802	0	1	04	01	H5533_802_0	6	1	20% Coinsurance	11	011111111111111000011111000111101111	000011100000000100000010	2		2			2		2	1			20	20				
H5533	802	0	1	04	01	H5533_802_0	6	2	50% Coinsurance	11	000000000000000000000000111000010000	000000000000000000110001	2		2			2		2	1			50	50				
H5533	803	0	1	04	01	H5533_803_0	4	4	$0 OON Cost Sharing	10		000000000000000000001100	2		1	0.00	0.00	2		2	2								
H5533	803	0	1	04	01	H5533_803_0	4	3	50% with $250 Annual allowance	10		000000000000000010000000	1	250.00	2			2		2	1			50	50				
H5533	803	0	1	04	01	H5533_803_0	4	2	50% Coinsurance	11	000000000000000000000000111000010000	000000000000000000110001	2		2			2		2	1			50	50				
H5533	803	0	1	04	01	H5533_803_0	4	1	20% Coinsurance	11	011111111111111000011111000111101111	000011100000000100000010	2		2			2		2	1			20	20				
H5533	803	0	1	04	01	H5533_803_0	4	5	20% Coins with PCP/Spec Copay	01	000000000000000111100000000000000000		2		2			2		1	1	1	20	20	20	20	2		
H5868	001	0	1	04	01	H5868_001_0	6	6		01	000000000000000000000000000000010000		2		2			2		2	1			20	30				
H5868	001	0	1	04	01	H5868_001_0	6	5		10		000000000110000010000000	2		2			2		2	1			50	50				
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H5868	001	0	1	04	01	H5868_001_0	6	3		01	000000000000000000000000000100000000		2		2			2		2	1			0	20				
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H5868	004	0	1	04	01	H5868_004_0	3	6		01	000000000000000000000000000000010000		2		2			2		2	1			20	30				
H5868	004	0	1	04	01	H5868_004_0	3	5		10		000000000110000010110000	2		2			2		2	1			50	50				
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H5868	004	0	1	04	01	H5868_004_0	3	1		11	011111111111111111111100111001101101	000000000000000100000000	2		2			2		2	1			30	30				
H5868	004	0	1	04	01	H5868_004_0	3	7		01	000000000000000000000000000010000000		2		2			2		2	1			0	50				
H5970	001	0	1	04	01	H5970_001_0	7	5		01	000000000000000100100000000000000000		2		1	20.00	40.00	2		2	1			20	20				
H5970	001	0	1	04	01	H5970_001_0	7	6		01	000000000000000000000001000000000000		2		1	175.00	175.00	2		2	2								
H5970	001	0	1	04	01	H5970_001_0	7	7		01	000000000000000000000000000110000000		2		2			2		2	1			0	20				
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H6328	002	0	1	04	01	H6328_002_0	5	9	$175 Copay	01	000000000000000000001000000000000000		2		1	175.00	175.00	2		2	2								
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H6328	002	0	1	04	01	H6328_002_0	5	10	$225 Copay	01	000000000000000000010000000000000000		2		1	225.00	225.00	2		2	2								
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H6328	002	0	1	04	01	H6328_002_0	5	13	20% Coinsurance	01	000000000000000000000000001001100000		2		2			2		2	1			20	20				
H6328	002	0	1	04	01	H6328_002_0	5	12	$75 to $200 Copay	01	000000000000000010000000000000000000		2		1	75.00	200.00	2		2	2								
H6328	002	0	1	04	01	H6328_002_0	5	6	$55 Copay	01	000000000010010000000100000100000000		2		1	55.00	55.00	2		2	2								
H6328	002	0	1	04	01	H6328_002_0	5	7	$100 Copay	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
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H6328	003	0	1	04	01	H6328_003_0	5	11	$75 to $250 Copay	01	000000000000000010000000000000000000		2		1	75.00	250.00	2		2	2								
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H6328	005	0	1	04	01	H6328_005_0	3	6	$150 Copay	01	000000000000000000001000000000000000		2		1	150.00	150.00	2		2	2								
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H6328	006	0	1	04	01	H6328_006_0	3	6	$55 Copay	01	000000000010010000000100000100000000		2		1	55.00	55.00	2		2	2								
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H6328	006	0	1	04	01	H6328_006_0	3	12	$75 to $200 Copay	01	000000000000000010000000000000000000		2		1	75.00	200.00	2		2	2								
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H6328	803	0	1	04	01	H6328_803_0	4	1	20% Coinsurance	01	011111111111111111111111111111111111		2		2			2		2	1			20	20				
H6328	804	0	1	04	01	H6328_804_0	4	1	20% Coinsurance	01	011111111111111111111111111111111111		2		2			2		2	1			20	20				
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H6528	001	0	1	04	01	H6528_001_0	5	1	$50 Copayment	01	011100001101101000000000000000000011		2		1	50.00	50.00	2		2	2								
H6528	001	0	1	04	01	H6528_001_0	5	9	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H6528	001	0	1	04	01	H6528_001_0	5	11	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H6528	001	0	1	04	01	H6528_001_0	5	12	$175 Copayment	01	000000000000000000000001000000000000		2		1	175.00	175.00	2		2	2								
H6528	001	0	1	04	01	H6528_001_0	5	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H6528	001	0	1	04	01	H6528_001_0	5	14	$0 to $50 Copayment	01	000000000000000000000000000000000100		2		1	0.00	50.00	2		2	2								
H6528	001	0	1	04	01	H6528_001_0	5	15	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H6528	001	0	1	04	01	H6528_001_0	5	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H6528	001	0	1	04	01	H6528_001_0	5	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H6528	001	0	1	04	01	H6528_001_0	5	4	$30 Copayment	11	000000100000000000000000000000000000	000000000000000000001000	2		1	30.00	30.00	2		2	2								
H6528	001	0	1	04	01	H6528_001_0	5	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H6528	001	0	1	04	01	H6528_001_0	5	6	$30 to $40 Copayment	01	000000000010010000000100000000000000		2		1	30.00	40.00	2		2	2								
H6528	001	0	1	04	01	H6528_001_0	5	7	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H6528	001	0	1	04	01	H6528_001_0	5	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H6528	001	0	1	04	01	H6528_001_0	5	10	$195 Copayment	01	000000000000000000011000000000000000		2		1	195.00	195.00	2		2	2								
H6528	005	0	1	04	01	H6528_005_0	5	9	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H6528	005	0	1	04	01	H6528_005_0	5	1	$50 Copayment	01	011100001101101000000000000000000011		2		1	50.00	50.00	2		2	2								
H6528	005	0	1	04	01	H6528_005_0	5	10	$250 Copayment	01	000000000000000000011000000000000000		2		1	250.00	250.00	2		2	2								
H6528	005	0	1	04	01	H6528_005_0	5	11	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H6528	005	0	1	04	01	H6528_005_0	5	12	$185 Copayment	01	000000000000000000000001000000000000		2		1	185.00	185.00	2		2	2								
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H6528	005	0	1	04	01	H6528_005_0	5	14	$0 to $50 Copayment	01	000000000000000000000000000000000100		2		1	0.00	50.00	2		2	2								
H6528	005	0	1	04	01	H6528_005_0	5	15	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H6528	005	0	1	04	01	H6528_005_0	5	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H6528	005	0	1	04	01	H6528_005_0	5	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H6528	005	0	1	04	01	H6528_005_0	5	4	$30 Copayment	01	000000100000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H6528	005	0	1	04	01	H6528_005_0	5	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H6528	005	0	1	04	01	H6528_005_0	5	6	$30 to $40 Copayment	01	000000000010010000000100000000000000		2		1	30.00	40.00	2		2	2								
H6528	005	0	1	04	01	H6528_005_0	5	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H6528	005	0	1	04	01	H6528_005_0	5	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H6528	006	0	1	04	01	H6528_006_0	5	9	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H6528	006	0	1	04	01	H6528_006_0	5	4	$25 Copayment	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H6528	006	0	1	04	01	H6528_006_0	5	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H6528	006	0	1	04	01	H6528_006_0	5	6	$25 to $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
H6528	006	0	1	04	01	H6528_006_0	5	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H6528	006	0	1	04	01	H6528_006_0	5	1	$45 Copayment	01	011100001101101000000000000000000011		2		1	45.00	45.00	2		2	2								
H6528	006	0	1	04	01	H6528_006_0	5	10	$250 Copayment	01	000000000000000000011000000000000000		2		1	250.00	250.00	2		2	2								
H6528	006	0	1	04	01	H6528_006_0	5	11	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H6528	006	0	1	04	01	H6528_006_0	5	12	$110 Copayment	01	000000000000000000000001000000000000		2		1	110.00	110.00	2		2	2								
H6528	006	0	1	04	01	H6528_006_0	5	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H6528	006	0	1	04	01	H6528_006_0	5	14	$340 to $390 Coinsurance	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H6528	006	0	1	04	01	H6528_006_0	5	15	$0 to $45 Copayment	01	000000000000000000000000000000000100		2		1	0.00	45.00	2		2	2								
H6528	006	0	1	04	01	H6528_006_0	5	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H6528	006	0	1	04	01	H6528_006_0	5	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H6528	006	0	1	04	01	H6528_006_0	5	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H6528	007	0	1	04	01	H6528_007_0	4	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H6528	007	0	1	04	01	H6528_007_0	4	9	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H6528	007	0	1	04	01	H6528_007_0	4	7	$10 Copayment	10		000000000000000000101000	2		1	10.00	10.00	2		2	2								
H6528	007	0	1	04	01	H6528_007_0	4	6	$25 to $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
H6528	007	0	1	04	01	H6528_007_0	4	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H6528	007	0	1	04	01	H6528_007_0	4	1	$45 Copayment	01	011100001101101000000000000000000011		2		1	45.00	45.00	2		2	2								
H6528	007	0	1	04	01	H6528_007_0	4	10	$250 Copayment	01	000000000000000000011000000000000000		2		1	250.00	250.00	2		2	2								
H6528	007	0	1	04	01	H6528_007_0	4	11	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H6528	007	0	1	04	01	H6528_007_0	4	12	$120 Copayment	01	000000000000000000000001000000000000		2		1	120.00	120.00	2		2	2								
H6528	007	0	1	04	01	H6528_007_0	4	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H6528	007	0	1	04	01	H6528_007_0	4	14	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H6528	007	0	1	04	01	H6528_007_0	4	15	$0 to $45 Copayment	01	000000000000000000000000000000000100		2		1	0.00	45.00	2		2	2								
H6528	007	0	1	04	01	H6528_007_0	4	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H6528	007	0	1	04	01	H6528_007_0	4	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H6528	007	0	1	04	01	H6528_007_0	4	4	$25 Copayment	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H6528	009	0	1	04	01	H6528_009_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H6528	009	0	1	04	01	H6528_009_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H6528	009	0	1	04	01	H6528_009_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H6528	009	0	1	04	01	H6528_009_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000001010100000010011100	2		1	0.00	0.00	2		2	2								
H6528	009	0	1	04	01	H6528_009_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H6528	010	0	1	04	01	H6528_010_0	3	11	$0 Copayment	11	000000000000000000000010001011101000	000001110000000010000100	2		1	0.00	0.00	2		2	2								
H6528	010	0	1	04	01	H6528_010_0	3	12	$0 to $50 Copayment	01	000000000000000000000000000000000100		2		1	0.00	50.00	2		2	2								
H6528	010	0	1	04	01	H6528_010_0	3	10	$150 Copayment	01	000000000000000000011001000000000000		2		1	150.00	150.00	2		2	2								
H6528	010	0	1	04	01	H6528_010_0	3	1	$50 Copayment	01	011100001101101000000000000000000011		2		1	50.00	50.00	2		2	2								
H6528	010	0	1	04	01	H6528_010_0	3	9	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H6528	010	0	1	04	01	H6528_010_0	3	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H6528	010	0	1	04	01	H6528_010_0	3	7	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H6528	010	0	1	04	01	H6528_010_0	3	6	$25 to $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
H6528	010	0	1	04	01	H6528_010_0	3	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H6528	010	0	1	04	01	H6528_010_0	3	4	$25 Copayment	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H6528	010	0	1	04	01	H6528_010_0	3	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H6528	010	0	1	04	01	H6528_010_0	3	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H6528	010	0	1	04	01	H6528_010_0	3	14	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H6528	010	0	1	04	01	H6528_010_0	3	15	$30 Copayment	10		000000000000000000001000	2		1	30.00	30.00	2		2	2								
H6528	010	0	1	04	01	H6528_010_0	3	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H6528	011	0	1	04	01	H6528_011_0	3	3	$0 Copayment	11	000001000000000000000000000011100000	000000010000000010011100	2		1	0.00	0.00	2		2	2								
H6528	011	0	1	04	01	H6528_011_0	3	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H6528	011	0	1	04	01	H6528_011_0	3	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H6528	011	0	1	04	01	H6528_011_0	3	4	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H6528	011	0	1	04	01	H6528_011_0	3	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H6528	012	0	1	04	01	H6528_012_0	4	5	$330 to $380 Copayment	10		000000000000000000000001	2		1	330.00	380.00	2		2	2								
H6528	012	0	1	04	01	H6528_012_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H6528	012	0	1	04	01	H6528_012_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000001010100000010111100	2		1	0.00	0.00	2		2	2								
H6528	012	0	1	04	01	H6528_012_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H6528	012	0	1	04	01	H6528_012_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H6528	013	0	1	04	01	H6528_013_0	3	10	$150 Copayment	01	000000000000000000011000000000000000		2		1	150.00	150.00	2		2	2								
H6528	013	0	1	04	01	H6528_013_0	3	11	$0 Copayment	11	000000000000000000000010001011101100	000001110000000010000100	2		1	0.00	0.00	2		2	2								
H6528	013	0	1	04	01	H6528_013_0	3	12	$30 Copayment	10		000000000000000000001000	2		1	30.00	30.00	2		2	2								
H6528	013	0	1	04	01	H6528_013_0	3	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H6528	013	0	1	04	01	H6528_013_0	3	14	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H6528	013	0	1	04	01	H6528_013_0	3	15	$160 Copayment	01	000000000000000000000001000000000000		2		1	160.00	160.00	2		2	2								
H6528	013	0	1	04	01	H6528_013_0	3	2	$40 Copayment	01	000010000010010000000100000000000000		2		1	40.00	40.00	2		2	2								
H6528	013	0	1	04	01	H6528_013_0	3	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H6528	013	0	1	04	01	H6528_013_0	3	4	$25 Copayment	01	000000100010010000000100000000000000		2		1	25.00	25.00	2		2	2								
H6528	013	0	1	04	01	H6528_013_0	3	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H6528	013	0	1	04	01	H6528_013_0	3	6	$14 Copayment	01	000000000000000100000000000000000000		2		1	14.00	14.00	2		2	2								
H6528	013	0	1	04	01	H6528_013_0	3	7	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H6528	013	0	1	04	01	H6528_013_0	3	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H6528	013	0	1	04	01	H6528_013_0	3	9	$15 Copayment	01	000000000000000000100000000000000000		2		1	15.00	15.00	2		2	2								
H6528	013	0	1	04	01	H6528_013_0	3	1	$50 Copayment	01	011100001101101000000000000000000111		2		1	50.00	50.00	2		2	2								
H6528	014	0	1	04	01	H6528_014_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H6528	014	0	1	04	01	H6528_014_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H6528	014	0	1	04	01	H6528_014_0	4	3	$0 Copayment	11	000001000000000000000000000011100000	000000010000000010111100	2		1	0.00	0.00	2		2	2								
H6528	014	0	1	04	01	H6528_014_0	4	4	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H6528	014	0	1	04	01	H6528_014_0	4	5	$330 to $380 Copayment	10		000000000000000000000001	2		1	330.00	380.00	2		2	2								
H6528	015	0	1	04	01	H6528_015_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H6528	015	0	1	04	01	H6528_015_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H6528	015	0	1	04	01	H6528_015_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000001010100000010011100	2		1	0.00	0.00	2		2	2								
H6528	015	0	1	04	01	H6528_015_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H6528	015	0	1	04	01	H6528_015_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H6528	016	0	1	04	01	H6528_016_0	3	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H6528	016	0	1	04	01	H6528_016_0	3	15	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H6528	016	0	1	04	01	H6528_016_0	3	14	$0 to $45 Copayment	01	000000000000000000000000000000000100		2		1	0.00	45.00	2		2	2								
H6528	016	0	1	04	01	H6528_016_0	3	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H6528	016	0	1	04	01	H6528_016_0	3	12	$160 Copayment	01	000000000000000000000001000000000000		2		1	160.00	160.00	2		2	2								
H6528	016	0	1	04	01	H6528_016_0	3	11	$0 Copayment	11	000000000000000000000010001011101000	000001110000000010000100	2		1	0.00	0.00	2		2	2								
H6528	016	0	1	04	01	H6528_016_0	3	10	$195 Copayment	01	000000000000000000011000000000000000		2		1	195.00	195.00	2		2	2								
H6528	016	0	1	04	01	H6528_016_0	3	1	$45 Copayment	01	011100001101101000000000000000000011		2		1	45.00	45.00	2		2	2								
H6528	016	0	1	04	01	H6528_016_0	3	9	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H6528	016	0	1	04	01	H6528_016_0	3	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H6528	016	0	1	04	01	H6528_016_0	3	7	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H6528	016	0	1	04	01	H6528_016_0	3	6	$25 to $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
H6528	016	0	1	04	01	H6528_016_0	3	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H6528	016	0	1	04	01	H6528_016_0	3	4	$25 Copayment	11	000000100000000000000000000000000000	000000000000000000001000	2		1	25.00	25.00	2		2	2								
H6528	016	0	1	04	01	H6528_016_0	3	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H6528	017	0	1	04	01	H6528_017_0	3	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H6528	017	0	1	04	01	H6528_017_0	3	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H6528	017	0	1	04	01	H6528_017_0	3	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H6528	017	0	1	04	01	H6528_017_0	3	3	$0 Copayment	11	000001000000000000000000000011100000	000000010000000010011100	2		1	0.00	0.00	2		2	2								
H6528	017	0	1	04	01	H6528_017_0	3	4	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H6528	018	0	1	04	01	H6528_018_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H6528	018	0	1	04	01	H6528_018_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H6528	018	0	1	04	01	H6528_018_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H6528	018	0	1	04	01	H6528_018_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H6528	018	0	1	04	01	H6528_018_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000001010100000010011100	2		1	0.00	0.00	2		2	2								
H6528	019	0	1	04	01	H6528_019_0	3	14	$0 to $45 Copayment	01	000000000000000000000000000000000100		2		1	0.00	45.00	2		2	2								
H6528	019	0	1	04	01	H6528_019_0	3	15	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H6528	019	0	1	04	01	H6528_019_0	3	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H6528	019	0	1	04	01	H6528_019_0	3	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H6528	019	0	1	04	01	H6528_019_0	3	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H6528	019	0	1	04	01	H6528_019_0	3	12	$160 Copayment	01	000000000000000000000001000000000000		2		1	160.00	160.00	2		2	2								
H6528	019	0	1	04	01	H6528_019_0	3	11	$0 Copayment	11	000000000000000000000010001011101000	000001110000000010000100	2		1	0.00	0.00	2		2	2								
H6528	019	0	1	04	01	H6528_019_0	3	10	$195 Copayment	01	000000000000000000011000000000000000		2		1	195.00	195.00	2		2	2								
H6528	019	0	1	04	01	H6528_019_0	3	1	$45 Copayment	01	011100001101101000000000000000000011		2		1	45.00	45.00	2		2	2								
H6528	019	0	1	04	01	H6528_019_0	3	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H6528	019	0	1	04	01	H6528_019_0	3	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H6528	019	0	1	04	01	H6528_019_0	3	6	$25 to $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
H6528	019	0	1	04	01	H6528_019_0	3	4	$25 Copayment	11	000000100000000000000000000000000000	000000000000000000001000	2		1	25.00	25.00	2		2	2								
H6528	019	0	1	04	01	H6528_019_0	3	9	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H6528	019	0	1	04	01	H6528_019_0	3	7	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H6528	020	0	1	04	01	H6528_020_0	3	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H6528	020	0	1	04	01	H6528_020_0	3	4	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H6528	020	0	1	04	01	H6528_020_0	3	3	$0 Copayment	11	000001000000000000000000000011100000	000000010000000010011100	2		1	0.00	0.00	2		2	2								
H6528	020	0	1	04	01	H6528_020_0	3	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H6528	020	0	1	04	01	H6528_020_0	3	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H6528	021	0	1	04	01	H6528_021_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H6528	021	0	1	04	01	H6528_021_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H6528	021	0	1	04	01	H6528_021_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H6528	021	0	1	04	01	H6528_021_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000000010100000010011100	2		1	0.00	0.00	2		2	2								
H6528	021	0	1	04	01	H6528_021_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H6528	022	0	1	04	01	H6528_022_0	3	1	$50 Copayment	01	011100001101101000000000000000000011		2		1	50.00	50.00	2		2	2								
H6528	022	0	1	04	01	H6528_022_0	3	10	$150 Copayment	01	000000000000000000011001000000000000		2		1	150.00	150.00	2		2	2								
H6528	022	0	1	04	01	H6528_022_0	3	11	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H6528	022	0	1	04	01	H6528_022_0	3	12	$0 to $50 Copayment	01	000000000000000000000000000000000100		2		1	0.00	50.00	2		2	2								
H6528	022	0	1	04	01	H6528_022_0	3	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H6528	022	0	1	04	01	H6528_022_0	3	14	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H6528	022	0	1	04	01	H6528_022_0	3	15	$30 Copayment	10		000000000000000000001000	2		1	30.00	30.00	2		2	2								
H6528	022	0	1	04	01	H6528_022_0	3	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H6528	022	0	1	04	01	H6528_022_0	3	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H6528	022	0	1	04	01	H6528_022_0	3	4	$25 Copayment	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H6528	022	0	1	04	01	H6528_022_0	3	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H6528	022	0	1	04	01	H6528_022_0	3	6	$25 to $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
H6528	022	0	1	04	01	H6528_022_0	3	7	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H6528	022	0	1	04	01	H6528_022_0	3	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H6528	022	0	1	04	01	H6528_022_0	3	9	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H6528	023	0	1	04	01	H6528_023_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H6528	023	0	1	04	01	H6528_023_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000000010100000010111100	2		1	0.00	0.00	2		2	2								
H6528	023	0	1	04	01	H6528_023_0	4	5	$330 to $380 Copayment	10		000000000000000000000001	2		1	330.00	380.00	2		2	2								
H6528	023	0	1	04	01	H6528_023_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H6528	023	0	1	04	01	H6528_023_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H6528	024	0	1	04	01	H6528_024_0	3	4	$25 Copayment	01	000000100010010000000100000000000000		2		1	25.00	25.00	2		2	2								
H6528	024	0	1	04	01	H6528_024_0	3	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H6528	024	0	1	04	01	H6528_024_0	3	2	$40 Copayment	01	000010000010010000000100000000000000		2		1	40.00	40.00	2		2	2								
H6528	024	0	1	04	01	H6528_024_0	3	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H6528	024	0	1	04	01	H6528_024_0	3	14	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H6528	024	0	1	04	01	H6528_024_0	3	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H6528	024	0	1	04	01	H6528_024_0	3	6	$13 Copayment	01	000000000000000100000000000000000000		2		1	13.00	13.00	2		2	2								
H6528	024	0	1	04	01	H6528_024_0	3	7	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H6528	024	0	1	04	01	H6528_024_0	3	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H6528	024	0	1	04	01	H6528_024_0	3	9	$15 Copayment	01	000000000000000000100000000000000000		2		1	15.00	15.00	2		2	2								
H6528	024	0	1	04	01	H6528_024_0	3	15	$180 Copayment	01	000000000000000000000001000000000000		2		1	180.00	180.00	2		2	2								
H6528	024	0	1	04	01	H6528_024_0	3	12	$30 Copayment	10		000000000000000000001000	2		1	30.00	30.00	2		2	2								
H6528	024	0	1	04	01	H6528_024_0	3	11	$0 Copayment	11	000000000000000000000010001011101100	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H6528	024	0	1	04	01	H6528_024_0	3	10	$150 Copayment	01	000000000000000000011000000000000000		2		1	150.00	150.00	2		2	2								
H6528	024	0	1	04	01	H6528_024_0	3	1	$50 Copayment	01	011100001101101000000000000000000111		2		1	50.00	50.00	2		2	2								
H6528	025	0	1	04	01	H6528_025_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000000010100000010011100	2		1	0.00	0.00	2		2	2								
H6528	025	0	1	04	01	H6528_025_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H6528	025	0	1	04	01	H6528_025_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H6528	025	0	1	04	01	H6528_025_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H6528	025	0	1	04	01	H6528_025_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H6528	026	0	1	04	01	H6528_026_0	3	9	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H6528	026	0	1	04	01	H6528_026_0	3	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H6528	026	0	1	04	01	H6528_026_0	3	7	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H6528	026	0	1	04	01	H6528_026_0	3	6	$25 to $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
H6528	026	0	1	04	01	H6528_026_0	3	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H6528	026	0	1	04	01	H6528_026_0	3	4	$25 Copayment	11	000000100000000000000000000000000000	000000000000000000001000	2		1	25.00	25.00	2		2	2								
H6528	026	0	1	04	01	H6528_026_0	3	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H6528	026	0	1	04	01	H6528_026_0	3	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H6528	026	0	1	04	01	H6528_026_0	3	15	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H6528	026	0	1	04	01	H6528_026_0	3	14	$0 to $45 Copayment	01	000000000000000000000000000000000100		2		1	0.00	45.00	2		2	2								
H6528	026	0	1	04	01	H6528_026_0	3	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H6528	026	0	1	04	01	H6528_026_0	3	12	$160 Copayment	01	000000000000000000000001000000000000		2		1	160.00	160.00	2		2	2								
H6528	026	0	1	04	01	H6528_026_0	3	11	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H6528	026	0	1	04	01	H6528_026_0	3	1	$45 Copayment	01	011100001101101000000000000000000011		2		1	45.00	45.00	2		2	2								
H6528	026	0	1	04	01	H6528_026_0	3	10	$195 Copayment	01	000000000000000000011000000000000000		2		1	195.00	195.00	2		2	2								
H6528	027	0	1	04	01	H6528_027_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000000010100000010011100	2		1	0.00	0.00	2		2	2								
H6528	027	0	1	04	01	H6528_027_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
H6528	027	0	1	04	01	H6528_027_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
H6528	027	0	1	04	01	H6528_027_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
H6528	027	0	1	04	01	H6528_027_0	4	5	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H6528	028	0	1	04	01	H6528_028_0	3	14	$0 to $45 Copayment	01	000000000000000000000000000000000100		2		1	0.00	45.00	2		2	2								
H6528	028	0	1	04	01	H6528_028_0	3	15	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
H6528	028	0	1	04	01	H6528_028_0	3	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H6528	028	0	1	04	01	H6528_028_0	3	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
H6528	028	0	1	04	01	H6528_028_0	3	4	$25 Copayment	11	000000100000000000000000000000000000	000000000000000000001000	2		1	25.00	25.00	2		2	2								
H6528	028	0	1	04	01	H6528_028_0	3	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H6528	028	0	1	04	01	H6528_028_0	3	6	$25 to $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
H6528	028	0	1	04	01	H6528_028_0	3	7	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
H6528	028	0	1	04	01	H6528_028_0	3	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
H6528	028	0	1	04	01	H6528_028_0	3	9	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
H6528	028	0	1	04	01	H6528_028_0	3	12	$160 Copayment	01	000000000000000000000001000000000000		2		1	160.00	160.00	2		2	2								
H6528	028	0	1	04	01	H6528_028_0	3	11	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
H6528	028	0	1	04	01	H6528_028_0	3	10	$195 Copayment	01	000000000000000000011000000000000000		2		1	195.00	195.00	2		2	2								
H6528	028	0	1	04	01	H6528_028_0	3	1	$45 Copayment	01	011100001101101000000000000000000011		2		1	45.00	45.00	2		2	2								
H6528	028	0	1	04	01	H6528_028_0	3	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
H6609	001	0	1	04	01	H6609_001_0	6	7		01	000000000000000000000000000000010000		2		2			2		2	1			20	40				
H6609	001	0	1	04	01	H6609_001_0	6	6		10		000000000100000010110000	2		2			2		2	1			50	50				
H6609	001	0	1	04	01	H6609_001_0	6	5		11	000000000000000000000010000000000010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H6609	001	0	1	04	01	H6609_001_0	6	8		01	000000000000000000000000000010000000		2		2			2		2	1			0	50				
H6609	001	0	1	04	01	H6609_001_0	6	4		01	000000000000000000000000000100000000		2		2			2		2	1			0	20				
H6609	001	0	1	04	01	H6609_001_0	6	3		01	000000000000000000000000010000000000		2		2			2		2	1			30	30				
H6609	001	0	1	04	01	H6609_001_0	6	1		11	011111111111111111111100101001101101	000000000000000100000000	2		2			2		2	1			40	40				
H6609	001	0	1	04	01	H6609_001_0	6	2		01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H6609	003	0	1	04	01	H6609_003_0	5	7		01	000000000000000000000000000010000000		2		2			2		2	1			0	50				
H6609	003	0	1	04	01	H6609_003_0	5	6		01	000000000000000000000000000000010000		2		2			2		2	1			20	40				
H6609	003	0	1	04	01	H6609_003_0	5	5		10		000000000110000010110000	2		2			2		2	1			50	50				
H6609	003	0	1	04	01	H6609_003_0	5	3		01	000000000000000000000000000100000000		2		2			2		2	1			0	20				
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H7006	003	0	1	04	01	H7006_003_0	9	7	Home Health, ESRD	01	000001000000000000000000000100000000		2		2			2		2	1			20	20				
H7006	003	0	1	04	01	H7006_003_0	9	8	Part B Drugs	01	000000000000000000000000000000010000		2		2			2		2	1			20	20				
H7006	003	0	1	04	01	H7006_003_0	9	6	Diagnostic Radiology	01	000000000000000011100000000000000000		2		2			2		2	1			20	30				
H7006	003	0	1	04	01	H7006_003_0	9	5	DME	01	000000000000000000000000110000000000		2		2			2		2	1			30	30				
H7006	003	0	1	04	01	H7006_003_0	9	4	Ambulance	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H7006	003	0	1	04	01	H7006_003_0	9	3	Outpatient Services/ASC	01	000000000000000000011000000000000000		2		1	225.00	225.00	2		2	2								
H7006	003	0	1	04	01	H7006_003_0	9	2	Office Visits	11	011110111111111000000100000000001101	000000000000000000101000	2		1	35.00	35.00	2		2	2								
H7006	003	0	1	04	01	H7006_003_0	9	1	Preventive	11	000000000000000100000010001011100010	000000100000000010000100	2		1	0.00	0.00	2		2	2								
H7006	004	0	1	04	01	H7006_004_0	6	1	Preventive	11	000000000000000100000010001011100010	000000100000000010000100	2		1	0.00	0.00	2		2	2								
H7006	004	0	1	04	01	H7006_004_0	6	2	Office Visits	11	011110111111111000000100000000001101	000000000000000000101000	2		1	35.00	35.00	2		2	2								
H7006	004	0	1	04	01	H7006_004_0	6	3	Outpatient Services/ASC	01	000000000000000000011000000000000000		2		1	225.00	225.00	2		2	2								
H7006	004	0	1	04	01	H7006_004_0	6	4	Ambulance	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H7006	004	0	1	04	01	H7006_004_0	6	5	DME	01	000000000000000000000000110000000000		2		2			2		2	1			30	30				
H7006	004	0	1	04	01	H7006_004_0	6	6	Diagnostic Radiology	01	000000000000000011100000000000000000		2		2			2		2	1			20	30				
H7006	004	0	1	04	01	H7006_004_0	6	7	Home Health, ESRD	01	000001000000000000000000000100000000		2		2			2		2	1			20	20				
H7006	004	0	1	04	01	H7006_004_0	6	8	Part B Drugs	01	000000000000000000000000000000010000		2		2			2		2	1			20	20				
H7188	003	0	1	04	01	H7188_003_0	5	6		01	000000000000000000000000000000010000		2		2			2		2	1			20	40				
H7188	003	0	1	04	01	H7188_003_0	5	5		10		000000000110000010110000	2		2			2		2	1			50	50				
H7188	003	0	1	04	01	H7188_003_0	5	4		11	000000000000000000000010000000000010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H7188	003	0	1	04	01	H7188_003_0	5	3		01	000000000000000000000000000100000000		2		2			2		2	1			0	20				
H7188	003	0	1	04	01	H7188_003_0	5	2		01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H7188	003	0	1	04	01	H7188_003_0	5	1		11	011111111111111111111100111001101101	000010000000000100000000	2		2			2		2	1			40	40				
H7188	003	0	1	04	01	H7188_003_0	5	7		01	000000000000000000000000000010000000		2		2			2		2	1			0	50				
H7188	006	0	1	04	01	H7188_006_0	6	6		01	000000000000000000000000000000010000		2		2			2		2	1			20	40				
H7188	006	0	1	04	01	H7188_006_0	6	5		10		000000000110000010000000	2		2			2		2	1			50	50				
H7188	006	0	1	04	01	H7188_006_0	6	4		11	000000000000000000000010000000000010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H7188	006	0	1	04	01	H7188_006_0	6	3		01	000000000000000000000000000100000000		2		2			2		2	1			0	20				
H7188	006	0	1	04	01	H7188_006_0	6	2		01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H7188	006	0	1	04	01	H7188_006_0	6	1		11	011111111111111111111100111001101101	000010000000000100000000	2		2			2		2	1			40	40				
H7188	006	0	1	04	01	H7188_006_0	6	7		01	000000000000000000000000000010000000		2		2			2		2	1			0	50				
H7301	002	0	1	04	01	H7301_002_0	7	5	Hearing Aids	10		000000000000000000000001	2		1	0.00	0.00	2		2	2								
H7301	002	0	1	04	01	H7301_002_0	7	1	Out of Network Coinsuance Group 1	11	011111111111111111111110111111111111	000001100000000000001000	2		2			2		2	1			30	30				
H7301	002	0	1	04	01	H7301_002_0	7	3	Out of Network Coinsurance Group 2	10		000000000000000000100000	2		2			1	75.00	2	1			30	30				
H7301	002	0	1	04	01	H7301_002_0	7	4	Out of Network Copay Group 2	10		000000000000000010000000	2		1	50.00	50.00	2		2	2								
H7301	002	0	1	04	01	H7301_002_0	7	2	Out of Network Copay Group 1	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
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H7301	801	0	1	04	01	H7301_801_0	5	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H7301	801	0	1	04	01	H7301_801_0	5	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H7301	802	0	1	04	01	H7301_802_0	5	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H7301	802	0	1	04	01	H7301_802_0	5	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H7301	802	0	1	04	01	H7301_802_0	5	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H7301	803	0	1	04	01	H7301_803_0	5	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H7301	803	0	1	04	01	H7301_803_0	5	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H7301	803	0	1	04	01	H7301_803_0	5	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H7306	001	0	1	04	01	H7306_001_0	13	1	Group 1	11	000000000000000001011110110111111101	000000100000000000001000	2		2			2		2	1			30	30				
H7306	001	0	1	04	01	H7306_001_0	13	2	Group 2	01	000000000000000000000001000000000000		2		2			2		2	1			20	20				
H7306	001	0	1	04	01	H7306_001_0	13	3	Group 3	11	000001000000000000000000000000000010	000000000000000010000100	2		1	0.00	0.00	2		2	2								
H7306	001	0	1	04	01	H7306_001_0	13	4	Group 4	10		000000000000000010000000	2		1	0.00	50.00	2		2	2								
H7306	001	0	1	04	01	H7306_001_0	13	6	Group 6	01	011110111111111110100000000000000000		2		2			2		2	1			35	35				
H7306	001	0	1	04	01	H7306_001_0	13	5	Group 5	01	000000000000000000000000001000000000		2		2			2		2	1			20	30				
H7306	003	0	1	04	01	H7306_003_0	9	6	Group 6	01	011110111111111100010000000000000000		2		2			2		2	1			30	30				
H7306	003	0	1	04	01	H7306_003_0	9	5	Group 5	01	000000000000000000000000001000000000		2		2			2		2	1			20	25				
H7306	003	0	1	04	01	H7306_003_0	9	4	Group 4	10		000000000000000010000000	2		1	50.00	50.00	2		2	2								
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H7306	003	0	1	04	01	H7306_003_0	9	3	Group 3	11	000001000000000000000000000000000010	000000000000000000100101	2		1	0.00	0.00	2		2	2								
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H7306	801	0	1	04	01	H7306_801_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H7306	801	0	1	04	01	H7306_801_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H7306	801	0	1	04	01	H7306_801_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H7306	803	0	1	04	01	H7306_803_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H7306	803	0	1	04	01	H7306_803_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H7306	803	0	1	04	01	H7306_803_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H7306	804	0	1	04	01	H7306_804_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H7306	804	0	1	04	01	H7306_804_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H7306	804	0	1	04	01	H7306_804_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H7728	001	0	1	04	01	H7728_001_0	13	1	$0 OON Copay Group	11	000000000000000000000000000000001100	000000000000000010000000	2		1	0.00	0.00	2		2	2								
H7728	001	0	1	04	01	H7728_001_0	13	10	Outpatient Hospital	01	000000000000000000010000000000000000		2		1	40.00	65.00	2		2	1			25	25				
H7728	001	0	1	04	01	H7728_001_0	13	9	Preventative Services	01	000000000000000000000000000010000000		2		1	0.00	0.00	2		2	1			30	30				
H7728	001	0	1	04	01	H7728_001_0	13	8	20% OON Coinsurance Group	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H7728	001	0	1	04	01	H7728_001_0	13	7	25% OON Coinsurance Group	01	000000000000000000001000000000000000		2		2			2		2	1			25	25				
H7728	001	0	1	04	01	H7728_001_0	13	6	$40 OON Copay Group	01	000000100000100000000000000000000000		2		1	40.00	40.00	2		2	2								
H7728	001	0	1	04	01	H7728_001_0	13	5	$200 OON Copay Group	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H7728	001	0	1	04	01	H7728_001_0	13	2	30% OON Coinsurance Group	11	000011000000000111100010111001110011	000000100000000000000000	2		2			2		2	1			30	30				
H7728	001	0	1	04	01	H7728_001_0	13	3	$45 OON Copay Group	01	000000010000000000000000000000000000		2		1	45.00	45.00	2		2	2								
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H7787	001	0	1	04	01	H7787_001_0	6	7	$0-$60 Copay	11	000000000000000000000000000000000100	000000000000000010001000	2		1	0.00	60.00	2		2	2								
H7787	001	0	1	04	01	H7787_001_0	6	6	50% Coinsurance	10		000000000000000000100000	2		2			2		2	1			50	50				
H7787	001	0	1	04	01	H7787_001_0	6	9	30% Coinsurance	01	000000000000000111100000000000000000		2		2			2		1	1	2		30	30		1	40.00	60.00
H7787	001	0	1	04	01	H7787_001_0	6	8	0%-30% Coinsurance	11	000000000000000000000000000000000010	000000000000000000000100	2		2			2		2	1			0	30				
H7787	001	0	1	04	01	H7787_001_0	6	5	$40-$60 Copay	01	000000000000000000000000000011100001		2		1	40.00	60.00	2		2	2								
H7787	001	0	1	04	01	H7787_001_0	6	4	$50 Copay	01	000000000000000000000001000000000000		2		1	50.00	50.00	2		2	2								
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H7787	001	0	1	04	01	H7787_001_0	6	1	30% Coinsurance	11	011110000010010000011110111100011000	000000100000000000000000	2		2			2		2	1			30	30				
H7787	002	0	1	04	01	H7787_002_0	4	7	0%-30% Coinsurance	11	000000000000000000000000000000000010	000000000000000000000100	2		2			2		2	1			0	30				
H7787	002	0	1	04	01	H7787_002_0	4	8	30% Coinsurance	01	000000000000000111100000000000000000		2		2			2		1	1	2		30	30		1	40.00	60.00
H7787	002	0	1	04	01	H7787_002_0	4	6	$0-$60 Copay	11	000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	60.00	2		2	2								
H7787	002	0	1	04	01	H7787_002_0	4	5	$40-$60 Copay	01	000000000000000000000000000011100001		2		1	40.00	60.00	2		2	2								
H7787	002	0	1	04	01	H7787_002_0	4	4	$50 Copay	01	000000000000000000000001000000000000		2		1	50.00	50.00	2		2	2								
H7787	002	0	1	04	01	H7787_002_0	4	3	$60 Copay	01	000000011101101000000000000000000000		2		1	60.00	60.00	2		2	2								
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H7787	002	0	1	04	01	H7787_002_0	4	1	30% Coinsurance	11	011110000010010000011110111100011000	000000100000000000000000	2		2			2		2	1			30	30				
H7917	008	0	1	04	01	H7917_008_0	10	5	20% Cost Share	01	000000000000000000000000001101100000		2		2			2		2	1			20	20				
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H8552	002	0	1	04	01	H8552_002_0	9	1	30% OON Coinsurance Group	11	011111001010011111100110000001100001	000000100000000000000000	2		2			2		2	1			30	30				
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H8552	011	0	1	04	01	H8552_011_0	8	1	30% OON Coinsurance Group	11	011111001010011011100110000001100001	000000100000000000000000	2		2			2		2	1			30	30				
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H8552	015	0	1	04	01	H8552_015_0	9	7	$0 OON Copayment	11	000000000000000000000000000000001110	000000000000000010000000	2		1	0.00	0.00	2		2	2								
H8552	015	0	1	04	01	H8552_015_0	9	6	20% OON Coinsurance	01	000000000000000000000000000100010000		2		2			2		2	1			20	20				
H8552	015	0	1	04	01	H8552_015_0	9	5	25% OON Coinsurance Group	01	000000000000000000011000111000000000		2		2			2		2	1			25	25				
H8552	015	0	1	04	01	H8552_015_0	9	4	$200 OON Copayment Group	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H8552	015	0	1	04	01	H8552_015_0	9	3	$40 OON Copayment Group	01	000000010000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H8552	015	0	1	04	01	H8552_015_0	9	1	30% OON Coinsurance Group	11	011111001010011011100110000001100001	000000100000000000000000	2		2			2		2	1			30	30				
H8552	015	0	1	04	01	H8552_015_0	9	2	$35 OON Copayment Group	01	000000100000100000000000000000000000		2		1	35.00	35.00	2		2	2								
H8552	017	0	1	04	01	H8552_017_0	9	8	$0 - 30% OON Group	01	000000000000000100000000000010000000		2		1	0.00	0.00	2		2	1			30	30				
H8552	017	0	1	04	01	H8552_017_0	9	7	$0 OON Copayment	11	000000000000000000000000000000001110	000000000000000010000000	2		1	0.00	0.00	2		2	2								
H8552	017	0	1	04	01	H8552_017_0	9	6	20% OON Coinsurance	01	000000000000000000000000000100010000		2		2			2		2	1			20	20				
H8552	017	0	1	04	01	H8552_017_0	9	5	25% OON Coinsurance Group	01	000000000000000000011000111000000000		2		2			2		2	1			25	25				
H8552	017	0	1	04	01	H8552_017_0	9	9	$55 OON Copayment Group	01	000000000101000000000000000010000000		2		1	55.00	55.00	2		2	2								
H8552	017	0	1	04	01	H8552_017_0	9	3	$40 OON Copayment Group	01	000000010000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H8552	017	0	1	04	01	H8552_017_0	9	2	$35 OON Copayment Group	01	000000100000100000000000000000000000		2		1	35.00	35.00	2		2	2								
H8552	017	0	1	04	01	H8552_017_0	9	1	30% OON Coinsurance Group	11	011111001010011011100110000001100001	000000100000000000000000	2		2			2		2	1			30	30				
H8552	017	0	1	04	01	H8552_017_0	9	4	$200 OON Copayment Group	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H8552	801	0	1	04	01	H8552_801_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H8552	801	0	1	04	01	H8552_801_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H8552	801	0	1	04	01	H8552_801_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H8552	802	0	1	04	01	H8552_802_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H8552	802	0	1	04	01	H8552_802_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H8552	802	0	1	04	01	H8552_802_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H8552	803	0	1	04	01	H8552_803_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H8552	803	0	1	04	01	H8552_803_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H8552	803	0	1	04	01	H8552_803_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H8558	014	0	1	04	01	H8558_014_0	6	7	Meal Benefit	10		000000000010000000000000	2		2			2		2	2								
H8558	014	0	1	04	01	H8558_014_0	6	6	0% to 20% Cost share	01	011100000000000100100000111000000000		2		2			2		2	1			0	20				
H8558	014	0	1	04	01	H8558_014_0	6	5	Supplemental-Routine Eye Wear	10		000000000000000000000100	1	125.00	2			2		2	2								
H8558	014	0	1	04	01	H8558_014_0	6	4	35% cost share	01	000010000010010000000000000100000000		2		2			2		2	1			35	35				
H8558	014	0	1	04	01	H8558_014_0	6	3	20% cost share	01	000000111101101011011111000000011000		2		2			2		2	1			20	20				
H8558	014	0	1	04	01	H8558_014_0	6	2	Supplemental -Dental	10		000000000000000000110000	1	400.00	1	0.00	0.00	2		2	2								
H8558	014	0	1	04	01	H8558_014_0	6	1	Zero Cost Share	11	000001000000000000000000000011100111	000000010001000000000000	2		2			2		2	1			0	0				
H8558	014	0	1	04	01	H8558_014_0	6	8	Supplemental-Routine Eye Exams	10		000000000000000000001000	1	50.00	2			2		2	2								
H8558	015	0	1	04	01	H8558_015_0	6	7	Meal Benefit	10		000000000010000000000000	2		2			2		2	2								
H8558	015	0	1	04	01	H8558_015_0	6	6	0% to 20% Cost share	01	011100000000000100100000111000000000		2		2			2		2	1			0	20				
H8558	015	0	1	04	01	H8558_015_0	6	5	Supplemental-Routine Eye Wear	10		000000000000000000000100	1	125.00	2			2		2	2								
H8558	015	0	1	04	01	H8558_015_0	6	4	35% cost share	01	000010000010010000000000000100000000		2		2			2		2	1			35	35				
H8558	015	0	1	04	01	H8558_015_0	6	3	20% cost share	01	000000111101101011011111000000011000		2		2			2		2	1			20	20				
H8558	015	0	1	04	01	H8558_015_0	6	2	Supplemental -Dental	10		000000000000000000110000	1	400.00	1	0.00	0.00	2		2	2								
H8558	015	0	1	04	01	H8558_015_0	6	1	Zero Cost Share	11	000001000000000000000000000011100111	000000010001000000000000	2		2			2		2	1			0	0				
H8558	015	0	1	04	01	H8558_015_0	6	8	Supplemental-Routine Eye Exams	10		000000000000000000001000	1	50.00	2			2		2	2								
H8558	016	0	1	04	01	H8558_016_0	7	7	Meals benefit	10		000000000010000000000000	2		2			2		2	2								
H8558	016	0	1	04	01	H8558_016_0	7	6	0% to 20% Cost share	01	011100000000000100100000111000000000		2		2			2		2	1			0	20				
H8558	016	0	1	04	01	H8558_016_0	7	5	Supplemental-Routine Eye Wear	10		000000000000000000000100	1	125.00	2			2		2	2								
H8558	016	0	1	04	01	H8558_016_0	7	4	35% cost share	01	000010000010010000000000000100000000		2		2			2		2	1			35	35				
H8558	016	0	1	04	01	H8558_016_0	7	3	20% cost share	01	000000111101101011011111000000011000		2		2			2		2	1			20	20				
H8558	016	0	1	04	01	H8558_016_0	7	2	Supplemental -Dental	10		000000000000000000110000	1	400.00	1	0.00	0.00	2		2	2								
H8558	016	0	1	04	01	H8558_016_0	7	1	Zero Cost Share	11	000001000000000000000000000011100111	000000010001000000000000	2		2			2		2	1			0	0				
H8558	016	0	1	04	01	H8558_016_0	7	8	Supplemental-Routine Eye Exams	10		000000000000000000001000	1	50.00	2			2		2	2								
H8558	017	0	1	04	01	H8558_017_0	7	8	Supplemental-Routine Eye Exams	10		000000000000000000001000	1	50.00	2			2		2	2								
H8558	017	0	1	04	01	H8558_017_0	7	7	Meal Benefit	10		000000000010000000000000	2		2			2		2	2								
H8558	017	0	1	04	01	H8558_017_0	7	6	0% to 20% Cost share	01	011100000000000100100000111000000000		2		2			2		2	1			0	20				
H8558	017	0	1	04	01	H8558_017_0	7	5	Supplemental-Routine Eye Wear	10		000000000000000000000100	1	125.00	2			2		2	2								
H8558	017	0	1	04	01	H8558_017_0	7	4	35% cost share	01	000010000010010000000000000100000000		2		2			2		2	1			35	35				
H8558	017	0	1	04	01	H8558_017_0	7	3	20% cost share	01	000000111101101011011111000000011000		2		2			2		2	1			20	20				
H8558	017	0	1	04	01	H8558_017_0	7	1	Zero Cost Share	11	000001000000000000000000000011100111	000000010001000000000000	2		2			2		2	1			0	0				
H8558	017	0	1	04	01	H8558_017_0	7	2	Supplemental -Dental	10		000000000000000000110000	1	400.00	1	0.00	0.00	2		2	2								
H8604	001	0	1	04	01	H8604_001_0	11	5	Group 5	01	000000000000000000000001000000000000		2		1	125.00	125.00	2		2	2								
H8604	001	0	1	04	01	H8604_001_0	11	4	Group 4	11	000000011111111000000100000000001101	000001000000000000001000	2		1	45.00	45.00	2		2	2								
H8604	001	0	1	04	01	H8604_001_0	11	3	Group 3	01	000000100000000000000000000000000000		2		1	20.00	45.00	2		2	2								
H8604	001	0	1	04	01	H8604_001_0	11	2	Group 2	01	000000000000000000000000111000000000		2		2			2		2	1			30	30				
H8604	001	0	1	04	01	H8604_001_0	11	1	Group 1	11	011111000000000111111010000111110010	000000100001000010000000	2		2			2		2	1			20	20				
H8604	001	0	1	04	01	H8604_001_0	11	6	Group 6	10		000000000000000000000100	2		2			2		2	1			20	20				
H8604	002	0	1	04	01	H8604_002_0	9	5	Group 5	01	000000000000000000000001000000000000		2		1	125.00	125.00	2		2	2								
H8604	002	0	1	04	01	H8604_002_0	9	4	Group 4	11	000000011111111000000100000000001101	000001000000000000001000	2		1	45.00	45.00	2		2	2								
H8604	002	0	1	04	01	H8604_002_0	9	3	Group 3	01	000000100000000000000000000000000000		2		1	20.00	45.00	2		2	2								
H8604	002	0	1	04	01	H8604_002_0	9	2	Group 2	01	000000000000000000000000111000000000		2		2			2		2	1			30	30				
H8604	002	0	1	04	01	H8604_002_0	9	1	Group 1	11	011111000000000111111010000111110010	000000100001000010000000	2		2			2		2	1			20	20				
H8604	002	0	1	04	01	H8604_002_0	9	6	Group 6	10		000000000000000000000100	2		2			2		2	1			20	20				
H8604	003	0	1	04	01	H8604_003_0	14	6	Group 6	10		000000000000000000000100	2		2			2		2	1			20	20				
H8604	003	0	1	04	01	H8604_003_0	14	1	Group 1	11	011111000000000111111010000111110010	000000100001000010000000	2		2			2		2	1			20	20				
H8604	003	0	1	04	01	H8604_003_0	14	2	Group 2	01	000000000000000000000000111000000000		2		2			2		2	1			30	30				
H8604	003	0	1	04	01	H8604_003_0	14	3	Group 3	01	000000100000000000000000000000000000		2		1	20.00	45.00	2		2	2								
H8604	003	0	1	04	01	H8604_003_0	14	4	Group 4	11	000000011111111000000100000000001101	000001000000000000001000	2		1	45.00	45.00	2		2	2								
H8604	003	0	1	04	01	H8604_003_0	14	5	Group 5	01	000000000000000000000001000000000000		2		1	125.00	125.00	2		2	2								
H8604	004	0	1	04	01	H8604_004_0	10	1	Group 1	11	011111000000000111111010000111110010	000000100001000010000000	2		2			2		2	1			20	20				
H8604	004	0	1	04	01	H8604_004_0	10	2	Group 2	01	000000000000000000000000111000000000		2		2			2		2	1			30	30				
H8604	004	0	1	04	01	H8604_004_0	10	3	Group 3	01	000000100000000000000000000000000000		2		1	20.00	45.00	2		2	2								
H8604	004	0	1	04	01	H8604_004_0	10	4	Group 4	11	000000011111111000000100000000001101	000001000000000000001000	2		1	45.00	45.00	2		2	2								
H8604	004	0	1	04	01	H8604_004_0	10	5	Group 5	01	000000000000000000000001000000000000		2		1	125.00	125.00	2		2	2								
H8604	004	0	1	04	01	H8604_004_0	10	6	Group 6	10		000000000000000000000100	2		2			2		2	1			20	20				
H8604	005	0	1	04	01	H8604_005_0	11	2	Group 2	01	000000000000000000000000111000000000		2		2			2		2	1			30	30				
H8604	005	0	1	04	01	H8604_005_0	11	6	Group 6	10		000000000000000000000100	2		2			2		2	1			20	20				
H8604	005	0	1	04	01	H8604_005_0	11	5	Group 5	01	000000000000000000000001000000000000		2		1	125.00	125.00	2		2	2								
H8604	005	0	1	04	01	H8604_005_0	11	4	Group 4	11	000000011111111000000100000000001101	000001000000000000001000	2		1	45.00	45.00	2		2	2								
H8604	005	0	1	04	01	H8604_005_0	11	3	Group 3	01	000000100000000000000000000000000000		2		1	20.00	45.00	2		2	2								
H8604	005	0	1	04	01	H8604_005_0	11	1	Group 1	11	011111000000000111111010000111110010	000000100001000010000000	2		2			2		2	1			20	20				
H8604	006	0	1	04	01	H8604_006_0	14	3	Group 3	01	000000100000000000000000000000000000		2		1	20.00	45.00	2		2	2								
H8604	006	0	1	04	01	H8604_006_0	14	2	Group 2	01	000000000000000000000000111000000000		2		2			2		2	1			30	30				
H8604	006	0	1	04	01	H8604_006_0	14	1	Group 1	11	011111000000000111111010000111110010	000000100001000010000000	2		2			2		2	1			20	20				
H8604	006	0	1	04	01	H8604_006_0	14	5	Group 5	01	000000000000000000000001000000000000		2		1	125.00	125.00	2		2	2								
H8604	006	0	1	04	01	H8604_006_0	14	4	Group 4	11	000000011111111000000100000000001101	000001000000000000001000	2		1	45.00	45.00	2		2	2								
H8604	006	0	1	04	01	H8604_006_0	14	6	Group 6	10		000000000000000000000100	2		2			2		2	1			20	20				
H8604	801	0	1	04	01	H8604_801_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H8604	801	0	1	04	01	H8604_801_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H8604	801	0	1	04	01	H8604_801_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H8604	802	0	1	04	01	H8604_802_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H8604	802	0	1	04	01	H8604_802_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H8604	802	0	1	04	01	H8604_802_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H8644	003	0	1	04	01	H8644_003_0	7	2		01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H8644	003	0	1	04	01	H8644_003_0	7	7		01	000000000000000000000000000010000000		2		2			2		2	1			0	50				
H8644	003	0	1	04	01	H8644_003_0	7	1		11	011111111111111111111100111001101101	000010000000000100000000	2		2			2		2	1			30	30				
H8644	003	0	1	04	01	H8644_003_0	7	3		01	000000000000000000000000000100000000		2		2			2		2	1			0	20				
H8644	003	0	1	04	01	H8644_003_0	7	4		11	000000000000000000000010000000000010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H8644	003	0	1	04	01	H8644_003_0	7	5		10		000000000110000010000000	2		2			2		2	1			50	50				
H8644	003	0	1	04	01	H8644_003_0	7	6		01	000000000000000000000000000000010000		2		2			2		2	1			20	30				
H8644	005	0	1	04	01	H8644_005_0	7	1		11	011111111111111111111100111001101101	000010000000000100000000	2		2			2		2	1			30	30				
H8644	005	0	1	04	01	H8644_005_0	7	2		01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H8644	005	0	1	04	01	H8644_005_0	7	4		11	000000000000000000000010000000000010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H8644	005	0	1	04	01	H8644_005_0	7	3		01	000000000000000000000000000100000000		2		2			2		2	1			0	20				
H8644	005	0	1	04	01	H8644_005_0	7	5		10		000000000000000010000000	2		2			2		2	1			50	50				
H8644	005	0	1	04	01	H8644_005_0	7	7		01	000000000000000000000000000010000000		2		2			2		2	1			0	50				
H8644	005	0	1	04	01	H8644_005_0	7	6		01	000000000000000000000000000000010000		2		2			2		2	1			20	30				
H8684	001	0	1	04	01	H8684_001_0	7	3	Tier 3	10		000000000000100010000101	2		2			2		2	2								
H8684	001	0	1	04	01	H8684_001_0	7	1	Tier 1	11	011111111111111111111110111111111111	000000000001000000001010	2		2			2		2	1			20	20				
H8684	001	0	1	04	01	H8684_001_0	7	2	Tier 2	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H8684	801	0	1	04	01	H8684_801_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H8684	801	0	1	04	01	H8684_801_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H8684	801	0	1	04	01	H8684_801_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H8684	802	0	1	04	01	H8684_802_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H8684	802	0	1	04	01	H8684_802_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H8684	802	0	1	04	01	H8684_802_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H8684	805	0	2	04	01	H8684_805_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H8684	805	0	2	04	01	H8684_805_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H8684	805	0	2	04	01	H8684_805_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H8684	806	0	2	04	01	H8684_806_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H8684	806	0	2	04	01	H8684_806_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H8684	806	0	2	04	01	H8684_806_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H8707	001	0	1	04	01	H8707_001_0	5	4		11	000000000000000000000010000000000010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H8707	001	0	1	04	01	H8707_001_0	5	6		01	000000000000000000000000000010000000		2		1	0.00	0.00	2		2	1			0	40				
H8707	001	0	1	04	01	H8707_001_0	5	5		10		000000000000000010110000	2		2			2		2	1			50	50				
H8707	001	0	1	04	01	H8707_001_0	5	3		01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H8707	001	0	1	04	01	H8707_001_0	5	2		01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
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H8707	003	0	1	04	01	H8707_003_0	6	4		01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
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H8707	003	0	1	04	01	H8707_003_0	6	6		10		000000000000000010000000	2		2			2		2	1			50	50				
H8707	003	0	1	04	01	H8707_003_0	6	5		11	000000000000000000000010000000000010	000000100000000000001000	2		1	0.00	0.00	2		2	2								
H8980	002	0	1	04	01	H8980_002_0	9	1	30% Coinsurance OON	11	011100111101101111111010111111111111	000001100001000000001010	2		2			2		2	1			30	30				
H8980	002	0	1	04	01	H8980_002_0	9	2	45% Coinsurance OON	01	000010000010010000000100000000000000		2		2			2		2	1			45	45				
H8980	002	0	1	04	01	H8980_002_0	9	3	0% Coinsurance OON	01	000001000000000000000000000000000000		2		2			2		2	2								
H8980	002	0	1	04	01	H8980_002_0	9	4	Ambulance OON	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
H8980	002	0	1	04	01	H8980_002_0	9	5	Gym OON - Monthly Copay	10		000000000000000010000000	2		1	50.00	50.00	2		2	2								
H8980	004	0	1	04	01	H8980_004_0	7	7	30% Coinsurance	10		000000000000000000100000	2		2			1	100.00	2	1			30	30				
H8980	004	0	1	04	01	H8980_004_0	7	8	50% Dental Coinsurance (Non-Medicare)	10		000000000000000000010000	2		2			1	100.00	2	1			50	50				
H8980	004	0	1	04	01	H8980_004_0	7	6	Hearing Aids OON	10		000000000000000000000001	2		2			2		2	1			50	50				
H8980	004	0	1	04	01	H8980_004_0	7	5	Gym OON - Monthly Copay	10		000000000000000010000000	2		1	50.00	50.00	2		2	2								
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H8980	004	0	1	04	01	H8980_004_0	7	2	45% Coinsurance OON	01	000010000010010000000100000000000000		2		2			2		2	1			45	45				
H8980	004	0	1	04	01	H8980_004_0	7	1	20% Coinsurance OON	11	011100111101101111111010111111111111	000001100001000000001010	2		2			2		2	1			20	20				
H8980	801	0	1	04	01	H8980_801_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H8980	801	0	1	04	01	H8980_801_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H8980	801	0	1	04	01	H8980_801_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H8980	802	0	1	04	01	H8980_802_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H8980	802	0	1	04	01	H8980_802_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H8980	802	0	1	04	01	H8980_802_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H8980	803	0	1	04	01	H8980_803_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H8980	803	0	1	04	01	H8980_803_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H8980	803	0	1	04	01	H8980_803_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H9412	001	0	1	04	01	H9412_001_0	6	3	All Other Medicare Services	11	011111011010011111111111111100010010	000000000000000010100000	2		2			2		2	1			20	20				
H9412	001	0	1	04	01	H9412_001_0	6	2	Specialist Physician Services	11	000000000101100000000000000011101101	000001000001000000001010	2		1	25.00	25.00	2		2	2								
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H9412	002	0	1	04	01	H9412_002_0	4	3	All Other Medicare Services	11	011111011010011111111111111100010000	000000000000000010000000	2		2			2		2	1			25	25				
H9412	002	0	1	04	01	H9412_002_0	4	1	Primary Care Physician Services	11	000000100000000000000000000000000000	000000000000000100000000	2		1	15.00	15.00	2		2	2								
H9412	002	0	1	04	01	H9412_002_0	4	2	Specialist Physician Services	11	000000000101100000000000000011101101	000001000001000000001010	2		1	30.00	30.00	2		2	2								
H9412	002	0	1	04	01	H9412_002_0	4	5	Eyewear OON	10		000000000000000000000100	1	200.00	1	0.00	0.00	2		2	2								
H9412	002	0	1	04	01	H9412_002_0	4	6	20% Coinsurance	11	000000000000000000000000000000000010	000000000000000000100000	2		2			2		2	1			20	20				
H9412	003	0	1	04	01	H9412_003_0	7	3	All Other Medicare Services	11	011111011010011111111111111100010000	000000000000000010000000	2		2			2		2	1			25	25				
H9412	003	0	1	04	01	H9412_003_0	7	2	Specialist Physician Services	11	000000000101100000000000000011101101	000001000001000000001010	2		1	30.00	30.00	2		2	2								
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H9412	003	0	1	04	01	H9412_003_0	7	6	20% Coinsurance	11	000000000000000000000000000000000010	000000000000000000100000	2		2			2		2	1			20	20				
H9412	003	0	1	04	01	H9412_003_0	7	5	Eyewear OON	10		000000000000000000000100	1	200.00	1	0.00	0.00	2		2	2								
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H9412	004	0	1	04	01	H9412_004_0	3	4	Hearing Aid	10		000000000000000000000001	1	1000.00	1	0.00	0.00	2		2	2								
H9412	004	0	1	04	01	H9412_004_0	3	2	Specialist Physician Services	11	000000000101100000000000000011101101	000001000001000000001010	2		1	25.00	25.00	2		2	2								
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H9412	801	0	1	04	01	H9412_801_0	2	2	OON Mental Health/Substance Abuse	01	000010000010010000000100000000000000		2		2			2		2	1			35	35				
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H9503	003	0	1	04	01	H9503_003_0	5	7		01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
H9503	006	0	1	04	01	H9503_006_0	6	4		10		000000000110000010000000	2		2			2		2	1			50	50				
H9503	006	0	1	04	01	H9503_006_0	6	1		11	011110111111111011111101111100011011	000001000000000000000000	2		2			2		2	1			20	20				
H9503	006	0	1	04	01	H9503_006_0	6	3		01	000000000000000100000000000000000100		2		2			2		2	1			0	20				
H9503	006	0	1	04	01	H9503_006_0	6	2		11	000001000000000000000010000011100000	000000100000000100001000	2		1	0.00	0.00	2		2	2								
H9572	001	1	1	04	01	H9572_001_1	10	2	DME  Prosthetics	01	000000000000000000000000110000000000		2		2			2		2	1			0	40				
H9572	001	1	1	04	01	H9572_001_1	10	3	Hearing	11	000000000000000000000000000000000001	000000000000000000000011	2		2			2		2	1			50	50				
H9572	001	1	1	04	01	H9572_001_1	10	4	Preventive Dental	10		000000000000000000100000	2		2			2		2	1			50	50				
H9572	001	1	1	04	01	H9572_001_1	10	5	Medicare Part B drugs	01	000000000000000000000000000000010000		2		2			2		2	1			0	40				
H9572	001	1	1	04	01	H9572_001_1	10	8	Bathroom Safety Bars	10		000000000100000000000000	1	100.00	2			2		2	1			50	50				
H9572	001	1	1	04	01	H9572_001_1	10	1	Global cost share group	11	011111111111111111111101000111001100	000000000000100110000000	2		2			2		2	1			40	40				
H9572	001	1	1	04	01	H9572_001_1	10	7	Zero cost share group	11	000000000000000000000010001000100010	000000100000000000000000	2		2			2		2	2								
H9572	001	1	1	04	01	H9572_001_1	10	6	Supplemental Vision	10		000000000000000000001100	2		1	0.00	10.00	2		2	2								
H9572	001	2	1	04	01	H9572_001_2	10	1	Global cost share group	11	011111111111111111111101000111001100	000000000000100110000000	2		2			2		2	1			40	40				
H9572	001	2	1	04	01	H9572_001_2	10	2	DME  Prosthetics	01	000000000000000000000000110000000000		2		2			2		2	1			0	40				
H9572	001	2	1	04	01	H9572_001_2	10	7	Zero cost share group	11	000000000000000000000010001000100010	000000100000000000000000	2		2			2		2	2								
H9572	001	2	1	04	01	H9572_001_2	10	4	Preventive Dental	10		000000000000000000100000	2		2			2		2	1			50	50				
H9572	001	2	1	04	01	H9572_001_2	10	3	Hearing	11	000000000000000000000000000000000001	000000000000000000000011	2		2			2		2	1			50	50				
H9572	001	2	1	04	01	H9572_001_2	10	8	Bathroom Safety Bars	10		000000000100000000000000	1	100.00	2			2		2	1			50	50				
H9572	001	2	1	04	01	H9572_001_2	10	6	Supplemental Vision	10		000000000000000000001100	2		1	0.00	10.00	2		2	2								
H9572	001	2	1	04	01	H9572_001_2	10	5	Medicare Part B drugs	01	000000000000000000000000000000010000		2		2			2		2	1			0	40				
H9572	001	3	1	04	01	H9572_001_3	10	5	Medicare Part B drugs	01	000000000000000000000000000000010000		2		2			2		2	1			0	40				
H9572	001	3	1	04	01	H9572_001_3	10	1	Global cost share group	11	011111111111111111111101000111001100	000000000000100110000000	2		2			2		2	1			40	40				
H9572	001	3	1	04	01	H9572_001_3	10	7	Zero cost share group	11	000000000000000000000010001000100010	000000100000000000000000	2		2			2		2	2								
H9572	001	3	1	04	01	H9572_001_3	10	8	Bathroom Safety Bars	10		000000000100000000000000	1	100.00	2			2		2	1			50	50				
H9572	001	3	1	04	01	H9572_001_3	10	6	Supplemental Vision	10		000000000000000000001100	2		1	0.00	10.00	2		2	2								
H9572	001	3	1	04	01	H9572_001_3	10	2	DME  Prosthetics	01	000000000000000000000000110000000000		2		2			2		2	1			0	40				
H9572	001	3	1	04	01	H9572_001_3	10	3	Hearing	11	000000000000000000000000000000000001	000000000000000000000011	2		2			2		2	1			50	50				
H9572	001	3	1	04	01	H9572_001_3	10	4	Preventive Dental	10		000000000000000000100000	2		2			2		2	1			50	50				
H9572	001	4	1	04	01	H9572_001_4	10	5	Medicare Part B drugs	01	000000000000000000000000000000010000		2		2			2		2	1			0	40				
H9572	001	4	1	04	01	H9572_001_4	10	1	Global cost share group	11	011111111111111111111101000111001100	000000000000100110000000	2		2			2		2	1			40	40				
H9572	001	4	1	04	01	H9572_001_4	10	7	Zero cost share group	11	000000000000000000000010001000100010	000000100000000000000000	2		2			2		2	2								
H9572	001	4	1	04	01	H9572_001_4	10	8	Bathroom Safety Bars	10		000000000100000000000000	1	100.00	2			2		2	1			50	50				
H9572	001	4	1	04	01	H9572_001_4	10	6	Supplemental Vision	10		000000000000000000001100	2		1	0.00	10.00	2		2	2								
H9572	001	4	1	04	01	H9572_001_4	10	2	DME  Prosthetics	01	000000000000000000000000110000000000		2		2			2		2	1			0	40				
H9572	001	4	1	04	01	H9572_001_4	10	3	Hearing	11	000000000000000000000000000000000001	000000000000000000000011	2		2			2		2	1			50	50				
H9572	001	4	1	04	01	H9572_001_4	10	4	Preventive Dental	10		000000000000000000100000	2		2			2		2	1			50	50				
H9572	001	6	1	04	01	H9572_001_6	10	5	Medicare Part B drugs	01	000000000000000000000000000000010000		2		2			2		2	1			0	40				
H9572	001	6	1	04	01	H9572_001_6	10	6	Supplemental Vision	10		000000000000000000001100	2		1	0.00	10.00	2		2	2								
H9572	001	6	1	04	01	H9572_001_6	10	7	Zero cost share group	11	000000000000000000000010001000100010	000000100000000000000000	2		2			2		2	2								
H9572	001	6	1	04	01	H9572_001_6	10	8	Bathroom Safety Bars	10		000000000100000000000000	1	100.00	2			2		2	1			50	50				
H9572	001	6	1	04	01	H9572_001_6	10	4	Preventive Dental	10		000000000000000000100000	2		2			2		2	1			50	50				
H9572	001	6	1	04	01	H9572_001_6	10	3	Hearing	11	000000000000000000000000000000000001	000000000000000000000011	2		2			2		2	1			50	50				
H9572	001	6	1	04	01	H9572_001_6	10	2	DME  Prosthetics	01	000000000000000000000000110000000000		2		2			2		2	1			0	40				
H9572	001	6	1	04	01	H9572_001_6	10	1	Global cost share group	11	011111111111111111111101000111001100	000000000000100110000000	2		2			2		2	1			40	40				
H9572	002	1	1	04	01	H9572_002_1	10	1	Global cost share group	11	011111111111111111111101000111001100	000000000000100110000000	2		2			2		2	1			40	40				
H9572	002	1	1	04	01	H9572_002_1	10	2	DME/Prosthetics	01	000000000000000000000000110000000000		2		2			2		2	1			40	40				
H9572	002	1	1	04	01	H9572_002_1	10	3	Hearing	11	000000000000000000000000000000000001	000000000000000000000011	2		2			2		2	1			50	50				
H9572	002	1	1	04	01	H9572_002_1	10	4	Preventive Dental	10		000000000000000000100000	2		2			2		2	1			50	50				
H9572	002	1	1	04	01	H9572_002_1	10	5	CMS Part B drugs	01	000000000000000000000000000000010000		2		2			2		2	1			0	40				
H9572	002	1	1	04	01	H9572_002_1	10	6	Supplemental Vision	10		000000000000000000001100	2		1	0.00	10.00	2		2	2								
H9572	002	1	1	04	01	H9572_002_1	10	7	Zero cost share services	11	000000000000000000000010001000100010	000000100000000000000000	2		2			2		2	2								
H9572	002	1	1	04	01	H9572_002_1	10	8	Bathroom Safety Bars	10		000000000100000000000000	1	100.00	2			2		2	1			50	50				
H9572	002	2	1	04	01	H9572_002_2	10	8	Bathroom Safety Bars	10		000000000100000000000000	1	100.00	2			2		2	1			50	50				
H9572	002	2	1	04	01	H9572_002_2	10	7	Zero cost share services	11	000000000000000000000010001000100010	000000100000000000000000	2		2			2		2	2								
H9572	002	2	1	04	01	H9572_002_2	10	6	Supplemental Vision	10		000000000000000000001100	2		1	0.00	10.00	2		2	2								
H9572	002	2	1	04	01	H9572_002_2	10	5	CMS Part B drugs	01	000000000000000000000000000000010000		2		2			2		2	1			0	40				
H9572	002	2	1	04	01	H9572_002_2	10	4	Preventive Dental	10		000000000000000000100000	2		2			2		2	1			50	50				
H9572	002	2	1	04	01	H9572_002_2	10	3	Hearing	11	000000000000000000000000000000000001	000000000000000000000011	2		2			2		2	1			50	50				
H9572	002	2	1	04	01	H9572_002_2	10	2	DME/Prosthetics	01	000000000000000000000000110000000000		2		2			2		2	1			40	40				
H9572	002	2	1	04	01	H9572_002_2	10	1	Global cost share group	11	011111111111111111111101000111001100	000000000000100110000000	2		2			2		2	1			40	40				
H9572	002	3	1	04	01	H9572_002_3	10	7	Zero cost share services	11	000000000000000000000010001000100010	000000100000000000000000	2		2			2		2	2								
H9572	002	3	1	04	01	H9572_002_3	10	8	Bathroom Safety Bars	10		000000000100000000000000	1	100.00	2			2		2	1			50	50				
H9572	002	3	1	04	01	H9572_002_3	10	6	Supplemental Vision	10		000000000000000000001100	2		1	0.00	10.00	2		2	2								
H9572	002	3	1	04	01	H9572_002_3	10	5	CMS Part B drugs	01	000000000000000000000000000000010000		2		2			2		2	1			0	40				
H9572	002	3	1	04	01	H9572_002_3	10	4	Preventive Dental	10		000000000000000000100000	2		2			2		2	1			50	50				
H9572	002	3	1	04	01	H9572_002_3	10	3	Hearing	11	000000000000000000000000000000000001	000000000000000000000011	2		2			2		2	1			50	50				
H9572	002	3	1	04	01	H9572_002_3	10	2	DME/Prosthetics	01	000000000000000000000000110000000000		2		2			2		2	1			40	40				
H9572	002	3	1	04	01	H9572_002_3	10	1	Global cost share group	11	011111111111111111111101000111001100	000000000000100110000000	2		2			2		2	1			40	40				
H9572	002	4	1	04	01	H9572_002_4	10	1	Global cost share group	11	011111111111111111111101000111001100	000000000000100110000000	2		2			2		2	1			40	40				
H9572	002	4	1	04	01	H9572_002_4	10	2	DME/Prosthetics	01	000000000000000000000000110000000000		2		2			2		2	1			40	40				
H9572	002	4	1	04	01	H9572_002_4	10	8	Bathroom Safety Bars	10		000000000100000000000000	1	100.00	2			2		2	1			50	50				
H9572	002	4	1	04	01	H9572_002_4	10	7	Zero cost share services	11	000000000000000000000010001000100010	000000100000000000000000	2		2			2		2	2								
H9572	002	4	1	04	01	H9572_002_4	10	6	Supplemental Vision	10		000000000000000000001100	2		1	0.00	10.00	2		2	2								
H9572	002	4	1	04	01	H9572_002_4	10	5	CMS Part B drugs	01	000000000000000000000000000000010000		2		2			2		2	1			0	40				
H9572	002	4	1	04	01	H9572_002_4	10	4	Preventive Dental	10		000000000000000000100000	2		2			2		2	1			50	50				
H9572	002	4	1	04	01	H9572_002_4	10	3	Hearing	11	000000000000000000000000000000000001	000000000000000000000011	2		2			2		2	1			50	50				
H9572	002	6	1	04	01	H9572_002_6	11	1	Global cost share group	11	011111111111111111111101000111001100	000000000000100110000000	2		2			2		2	1			40	40				
H9572	002	6	1	04	01	H9572_002_6	11	7	Zero cost share services	11	000000000000000000000010001000100010	000000100000000000000000	2		2			2		2	2								
H9572	002	6	1	04	01	H9572_002_6	11	6	Supplemental Vision	10		000000000000000000001100	2		1	0.00	10.00	2		2	2								
H9572	002	6	1	04	01	H9572_002_6	11	5	CMS Part B drugs	01	000000000000000000000000000000010000		2		2			2		2	1			0	40				
H9572	002	6	1	04	01	H9572_002_6	11	4	Preventive Dental	10		000000000000000000100000	2		2			2		2	1			50	50				
H9572	002	6	1	04	01	H9572_002_6	11	3	Hearing	11	000000000000000000000000000000000001	000000000000000000000011	2		2			2		2	1			50	50				
H9572	002	6	1	04	01	H9572_002_6	11	2	DME/Prosthetics	01	000000000000000000000000110000000000		2		2			2		2	1			40	40				
H9572	002	6	1	04	01	H9572_002_6	11	8	Bathroom Safety Bars	10		000000000100000000000000	1	100.00	2			2		2	1			50	50				
H9572	003	1	1	04	01	H9572_003_1	11	8	Bathroom Safety Bars	10		000000000100000000000000	1	100.00	2			2		2	1			50	50				
H9572	003	1	1	04	01	H9572_003_1	11	7	Zero cost share services	11	000000000000000000000010001000100010	000000100000000000000000	2		2			2		2	2								
H9572	003	1	1	04	01	H9572_003_1	11	6	Supplemental Vision	10		000000000000000000001100	2		1	0.00	10.00	2		2	2								
H9572	003	1	1	04	01	H9572_003_1	11	5	CMS Part B drugs	01	000000000000000000000000000000010000		2		2			2		2	1			0	30				
H9572	003	1	1	04	01	H9572_003_1	11	4	Preventative Dental	10		000000000000000000100000	2		2			2		2	1			50	50				
H9572	003	1	1	04	01	H9572_003_1	11	3	Hearing	11	000000000000000000000000000000000001	000000000000000000000011	2		2			2		2	1			50	50				
H9572	003	1	1	04	01	H9572_003_1	11	2	DME/Prosthetics	01	000000000000000000000000110000000000		2		2			2		2	1			0	30				
H9572	003	1	1	04	01	H9572_003_1	11	1	Global cost share	11	011111111111111111111101000111001100	000000000000100110000000	2		2			2		2	1			30	30				
H9572	003	2	1	04	01	H9572_003_2	11	7	Zero cost share services	11	000000000000000000000010001000100010	000000100000000000000000	2		2			2		2	2								
H9572	003	2	1	04	01	H9572_003_2	11	8	Bathroom Safety Bars	10		000000000100000000000000	1	100.00	2			2		2	1			50	50				
H9572	003	2	1	04	01	H9572_003_2	11	6	Supplemental Vision	10		000000000000000000001100	2		1	0.00	10.00	2		2	2								
H9572	003	2	1	04	01	H9572_003_2	11	5	CMS Part B drugs	01	000000000000000000000000000000010000		2		2			2		2	1			0	30				
H9572	003	2	1	04	01	H9572_003_2	11	4	Preventative Dental	10		000000000000000000100000	2		2			2		2	1			50	50				
H9572	003	2	1	04	01	H9572_003_2	11	3	Hearing	11	000000000000000000000000000000000001	000000000000000000000011	2		2			2		2	1			50	50				
H9572	003	2	1	04	01	H9572_003_2	11	2	DME/Prosthetics	01	000000000000000000000000110000000000		2		2			2		2	1			0	30				
H9572	003	2	1	04	01	H9572_003_2	11	1	Global cost share	11	011111111111111111111101000111001100	000000000000100110000000	2		2			2		2	1			30	30				
H9572	003	3	1	04	01	H9572_003_3	11	8	Bathroom Safety Bars	10		000000000100000000000000	1	100.00	2			2		2	1			50	50				
H9572	003	3	1	04	01	H9572_003_3	11	7	Zero cost share services	11	000000000000000000000010001000100010	000000100000000000000000	2		2			2		2	2								
H9572	003	3	1	04	01	H9572_003_3	11	6	Supplemental Vision	10		000000000000000000001100	2		1	0.00	10.00	2		2	2								
H9572	003	3	1	04	01	H9572_003_3	11	5	CMS Part B drugs	01	000000000000000000000000000000010000		2		2			2		2	1			0	30				
H9572	003	3	1	04	01	H9572_003_3	11	1	Global cost share	11	011111111111111111111101000111001100	000000000000100110000000	2		2			2		2	1			30	30				
H9572	003	3	1	04	01	H9572_003_3	11	2	DME/Prosthetics	01	000000000000000000000000110000000000		2		2			2		2	1			0	30				
H9572	003	3	1	04	01	H9572_003_3	11	3	Hearing	11	000000000000000000000000000000000001	000000000000000000000011	2		2			2		2	1			50	50				
H9572	003	3	1	04	01	H9572_003_3	11	4	Preventative Dental	10		000000000000000000100000	2		2			2		2	1			50	50				
H9572	003	4	1	04	01	H9572_003_4	11	6	Supplemental Vision	10		000000000000000000001100	2		1	0.00	10.00	2		2	2								
H9572	003	4	1	04	01	H9572_003_4	11	5	CMS Part B drugs	01	000000000000000000000000000000010000		2		2			2		2	1			0	30				
H9572	003	4	1	04	01	H9572_003_4	11	7	Zero cost share services	11	000000000000000000000010001000100010	000000100000000000000000	2		2			2		2	2								
H9572	003	4	1	04	01	H9572_003_4	11	8	Bathroom Safety Bars	10		000000000100000000000000	1	100.00	2			2		2	1			50	50				
H9572	003	4	1	04	01	H9572_003_4	11	4	Preventative Dental	10		000000000000000000100000	2		2			2		2	1			50	50				
H9572	003	4	1	04	01	H9572_003_4	11	3	Hearing	11	000000000000000000000000000000000001	000000000000000000000011	2		2			2		2	1			50	50				
H9572	003	4	1	04	01	H9572_003_4	11	2	DME/Prosthetics	01	000000000000000000000000110000000000		2		2			2		2	1			0	30				
H9572	003	4	1	04	01	H9572_003_4	11	1	Global cost share	11	011111111111111111111101000111001100	000000000000100110000000	2		2			2		2	1			30	30				
H9572	003	6	1	04	01	H9572_003_6	11	8	Bathroom Safety Bars	10		000000000100000000000000	1	100.00	2			2		2	1			50	50				
H9572	003	6	1	04	01	H9572_003_6	11	7	Zero cost share services	11	000000000000000000000010001000100010	000000100000000000000000	2		2			2		2	2								
H9572	003	6	1	04	01	H9572_003_6	11	6	Supplemental Vision	10		000000000000000000001100	2		1	0.00	10.00	2		2	2								
H9572	003	6	1	04	01	H9572_003_6	11	5	CMS Part B drugs	01	000000000000000000000000000000010000		2		2			2		2	1			0	30				
H9572	003	6	1	04	01	H9572_003_6	11	4	Preventative Dental	10		000000000000000000100000	2		2			2		2	1			50	50				
H9572	003	6	1	04	01	H9572_003_6	11	3	Hearing	11	000000000000000000000000000000000001	000000000000000000000011	2		2			2		2	1			50	50				
H9572	003	6	1	04	01	H9572_003_6	11	2	DME/Prosthetics	01	000000000000000000000000110000000000		2		2			2		2	1			0	30				
H9572	003	6	1	04	01	H9572_003_6	11	1	Global cost share	11	011111111111111111111101000111001100	000000000000100110000000	2		2			2		2	1			30	30				
H9572	004	1	1	04	01	H9572_004_1	11	1	Global cost share services	11	011111111111111111111101000111001100	000000000000100100000000	2		2			2		2	1			40	40				
H9572	004	1	1	04	01	H9572_004_1	11	2	DME/Prosthetics	01	000000000000000000000000110000000000		2		2			2		2	1			40	40				
H9572	004	1	1	04	01	H9572_004_1	11	6	Bathroom Safety Bars	10		000000000100000000000000	1	100.00	2			2		2	1			50	50				
H9572	004	1	1	04	01	H9572_004_1	11	4	CMS Part B drugs	01	000000000000000000000000000000010000		2		2			2		2	1			0	40				
H9572	004	1	1	04	01	H9572_004_1	11	5	Zero cost share services	11	000000000000000000000010001000100010	000000100000000000000000	2		2			2		2	2								
H9572	004	1	1	04	01	H9572_004_1	11	3	Hearing	01	000000000000000000000000000000000001		2		2			2		2	1			50	50				
H9572	004	2	1	04	01	H9572_004_2	11	2	DME/Prosthetics	01	000000000000000000000000110000000000		2		2			2		2	1			40	40				
H9572	004	2	1	04	01	H9572_004_2	11	3	Hearing	01	000000000000000000000000000000000001		2		2			2		2	1			50	50				
H9572	004	2	1	04	01	H9572_004_2	11	4	CMS Part B drugs	01	000000000000000000000000000000010000		2		2			2		2	1			0	40				
H9572	004	2	1	04	01	H9572_004_2	11	5	Zero cost share services	11	000000000000000000000010001000100010	000000100000000000000000	2		2			2		2	2								
H9572	004	2	1	04	01	H9572_004_2	11	6	Bathroom Safety Bars	10		000000000100000000000000	1	100.00	2			2		2	1			50	50				
H9572	004	2	1	04	01	H9572_004_2	11	1	Global cost share services	11	011111111111111111111101000111001100	000000000000100100000000	2		2			2		2	1			40	40				
H9572	004	3	1	04	01	H9572_004_3	11	1	Global cost share services	11	011111111111111111111101000111001100	000000000000100100000000	2		2			2		2	1			40	40				
H9572	004	3	1	04	01	H9572_004_3	11	2	DME/Prosthetics	01	000000000000000000000000110000000000		2		2			2		2	1			40	40				
H9572	004	3	1	04	01	H9572_004_3	11	3	Hearing	01	000000000000000000000000000000000001		2		2			2		2	1			50	50				
H9572	004	3	1	04	01	H9572_004_3	11	6	Bathroom Safety Bars	10		000000000100000000000000	1	100.00	2			2		2	1			50	50				
H9572	004	3	1	04	01	H9572_004_3	11	5	Zero cost share services	11	000000000000000000000010001000100010	000000100000000000000000	2		2			2		2	2								
H9572	004	3	1	04	01	H9572_004_3	11	4	CMS Part B drugs	01	000000000000000000000000000000010000		2		2			2		2	1			0	40				
H9572	004	4	1	04	01	H9572_004_4	11	6	Bathroom Safety Bars	10		000000000100000000000000	1	100.00	2			2		2	1			50	50				
H9572	004	4	1	04	01	H9572_004_4	11	3	Hearing	01	000000000000000000000000000000000001		2		2			2		2	1			50	50				
H9572	004	4	1	04	01	H9572_004_4	11	4	CMS Part B drugs	01	000000000000000000000000000000010000		2		2			2		2	1			0	40				
H9572	004	4	1	04	01	H9572_004_4	11	5	Zero cost share services	11	000000000000000000000010001000100010	000000100000000000000000	2		2			2		2	2								
H9572	004	4	1	04	01	H9572_004_4	11	2	DME/Prosthetics	01	000000000000000000000000110000000000		2		2			2		2	1			40	40				
H9572	004	4	1	04	01	H9572_004_4	11	1	Global cost share services	11	011111111111111111111101000111001100	000000000000100100000000	2		2			2		2	1			40	40				
H9572	004	6	1	04	01	H9572_004_6	11	3	Hearing	01	000000000000000000000000000000000001		2		2			2		2	1			50	50				
H9572	004	6	1	04	01	H9572_004_6	11	1	Global cost share services	11	011111111111111111111101000111001100	000000000000100100000000	2		2			2		2	1			40	40				
H9572	004	6	1	04	01	H9572_004_6	11	2	DME/Prosthetics	01	000000000000000000000000110000000000		2		2			2		2	1			40	40				
H9572	004	6	1	04	01	H9572_004_6	11	4	CMS Part B drugs	01	000000000000000000000000000000010000		2		2			2		2	1			0	40				
H9572	004	6	1	04	01	H9572_004_6	11	6	Bathroom Safety Bars	10		000000000100000000000000	1	100.00	2			2		2	1			50	50				
H9572	004	6	1	04	01	H9572_004_6	11	5	Zero cost share services	11	000000000000000000000010001000100010	000000100000000000000000	2		2			2		2	2								
H9572	801	0	1	04	01	H9572_801_0	6	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H9572	801	0	1	04	01	H9572_801_0	6	1		01	011111111101101111111111111111111111		2		2			2		2	1			20	20				
H9572	802	0	1	04	01	H9572_802_0	6	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H9572	802	0	1	04	01	H9572_802_0	6	1		01	011111111101101111111111111111111111		2		2			2		2	1			20	20				
H9572	803	0	1	04	01	H9572_803_0	6	1		01	011111111101101111111111111111111111		2		2			2		2	1			20	20				
H9572	803	0	1	04	01	H9572_803_0	6	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H9572	804	0	1	04	01	H9572_804_0	6	1		01	011111111101101111111111111111111111		2		2			2		2	1			20	20				
H9572	804	0	1	04	01	H9572_804_0	6	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H9615	002	0	1	04	01	H9615_002_0	9	1	25% Coinsurance	11	000001000000000111011000111000010010	000000000000000001000000	2		2			2		2	1			25	25				
H9615	002	0	1	04	01	H9615_002_0	9	2	$35 Copayment	11	011110101111111000100100000000001101	000000000000000000001010	2		1	35.00	35.00	2		2	2								
H9615	002	0	1	04	01	H9615_002_0	9	3	$20 Chiro	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H9615	002	0	1	04	01	H9615_002_0	9	4	$75 Copayment	01	000000000000000000000001000000000000		2		1	75.00	75.00	2		2	2								
H9615	002	0	1	04	01	H9615_002_0	9	6	$0 Copayment	11	000000000000000000000010000111100000	000000100100000010100001	2		1	0.00	0.00	2		2	2								
H9615	002	0	1	04	01	H9615_002_0	9	5	50% Acupuncture	10		000000001000000000000000	2		2			2		2	1			50	50				
H9615	007	0	1	04	01	H9615_007_0	5	6	$20 Chiro Copay	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
H9615	007	0	1	04	01	H9615_007_0	5	5	$0 Copayment	11	000000000000000000000010000111100000	000000100100000010000000	2		1	0.00	0.00	2		2	2								
H9615	007	0	1	04	01	H9615_007_0	5	4	50% Coinsurance	10		000000001000000000000000	2		2			2		2	1			50	50				
H9615	007	0	1	04	01	H9615_007_0	5	2	$60 Copayment	11	011110101111111000100100000000001101	000000000000000000001000	2		1	60.00	60.00	2		2	2								
H9615	007	0	1	04	01	H9615_007_0	5	3	$125 Ambulance	01	000000000000000000000001000000000000		2		1	125.00	125.00	2		2	2								
H9615	007	0	1	04	01	H9615_007_0	5	1	40% Coinsurance	11	000001000000000111011000111000010010	000000000000000001000000	2		2			2		2	1			40	40				
H9615	802	0	1	04	01	H9615_802_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H9615	802	0	1	04	01	H9615_802_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H9615	802	0	1	04	01	H9615_802_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H9615	804	0	1	04	01	H9615_804_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H9615	804	0	1	04	01	H9615_804_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H9615	804	0	1	04	01	H9615_804_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H9615	807	0	1	04	01	H9615_807_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H9615	807	0	1	04	01	H9615_807_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H9615	807	0	1	04	01	H9615_807_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H9615	808	0	1	04	01	H9615_808_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H9615	808	0	1	04	01	H9615_808_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H9615	808	0	1	04	01	H9615_808_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H9615	809	0	1	04	01	H9615_809_0	2	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H9615	809	0	1	04	01	H9615_809_0	2	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H9615	809	0	1	04	01	H9615_809_0	2	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H9670	004	0	1	04	01	H9670_004_0	13	1	30% Coinsurance	11	011111001000001000011011001111100010	000000100000000100000000	2		2			2		2	1			30	30				
H9670	004	0	1	04	01	H9670_004_0	13	4	$50 OON Copay	11	000000000111110000000100000000001101	000001000000000000000000	2		1	50.00	50.00	2		2	2								
H9670	004	0	1	04	01	H9670_004_0	13	6	50% with $250 annual max	10		000000000000000010000000	1	250.00	2			2		2	1			50	50				
H9670	004	0	1	04	01	H9670_004_0	13	7	50% OON	01	000000000000000000000000110000010000		2		2			2		2	1			50	50				
H9670	004	0	1	04	01	H9670_004_0	13	5	OON Routine Vision	10		000000000000000000001100	2		1	0.00	0.00	2		2	2								
H9670	004	0	1	04	01	H9670_004_0	13	3	$30 OON Copay	11	000000110000000000000000000000000000	000010000000000000000000	2		1	30.00	30.00	2		2	2								
H9670	004	0	1	04	01	H9670_004_0	13	2	30% coins - PCP/Spec Copay could apply	01	000000000000000111100000000000000000		2		2			2		1	1	2		30	30		1	30.00	50.00
H9670	801	0	1	04	01	H9670_801_0	7	4	$0 OON Cost Sharing	10		000000000000000000001100	2		1	0.00	0.00	2		2	2								
H9670	801	0	1	04	01	H9670_801_0	7	1	20% Coinsurance	11	011111111111111000011111000111101111	000011100000000100000010	2		2			2		2	1			20	20				
H9670	801	0	1	04	01	H9670_801_0	7	5	20% Coins with PCP/Spec Copay	01	000000000000000111100000000000000000		2		2			2		1	1	1	20	20	20	20	2		
H9670	801	0	1	04	01	H9670_801_0	7	2	50% Coinsurance	11	000000000000000000000000111000010000	000000000000000000110001	2		2			2		2	1			50	50				
H9670	801	0	1	04	01	H9670_801_0	7	3	50% with $250 Annual allowance	10		000000000000000010000000	1	250.00	2			2		2	1			50	50				
H9670	802	0	1	04	01	H9670_802_0	6	2	50% Coinsurance	11	000000000000000000000000111000010000	000000000000000000110001	2		2			2		2	1			50	50				
H9670	802	0	1	04	01	H9670_802_0	6	3	50% with $250 Annual allowance	10		000000000000000010000000	1	250.00	2			2		2	1			50	50				
H9670	802	0	1	04	01	H9670_802_0	6	5	20% Coins with PCP/Spec Copay	01	000000000000000111100000000000000000		2		2			2		1	1	1	20	20	20	20	2		
H9670	802	0	1	04	01	H9670_802_0	6	4	$0 OON Cost Sharing	10		000000000000000000001100	2		1	0.00	0.00	2		2	2								
H9670	802	0	1	04	01	H9670_802_0	6	1	20% Coinsurance	11	011111111111111000011111000111101111	000011100000000100000010	2		2			2		2	1			20	20				
H9670	803	0	1	04	01	H9670_803_0	5	5	20% Coins with PCP/Spec Copay	01	000000000000000111100000000000000000		2		2			2		1	1	1	20	20	20	20	2		
H9670	803	0	1	04	01	H9670_803_0	5	4	$0 OON Cost Sharing	10		000000000000000000001100	2		1	0.00	0.00	2		2	2								
H9670	803	0	1	04	01	H9670_803_0	5	2	50% Coinsurance	11	000000000000000000000000111000010000	000000000000000000110001	2		2			2		2	1			50	50				
H9670	803	0	1	04	01	H9670_803_0	5	1	20% Coinsurance	11	011111111111111000011111000111101111	000011100000000100000010	2		2			2		2	1			20	20				
H9670	803	0	1	04	01	H9670_803_0	5	3	50% with $250 Annual allowance	10		000000000000000010000000	1	250.00	2			2		2	1			50	50				
H9847	001	0	1	04	01	H9847_001_0	9	8	fitness	10		000000000000000010000000	2		1	0.00	50.00	2		2	2								
H9847	001	0	1	04	01	H9847_001_0	9	6	$45	11	000000001111111000000000000000001101	000000000001000000000000	2		1	45.00	45.00	2		2	2								
H9847	001	0	1	04	01	H9847_001_0	9	5	5	11	000000000000000000000000000011100000	000000100000000100101000	2		1	0.00	0.00	2		2	2								
H9847	001	0	1	04	01	H9847_001_0	9	4	4	01	000001000000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H9847	001	0	1	04	01	H9847_001_0	9	3	3	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
H9847	001	0	1	04	01	H9847_001_0	9	2	2	01	000000000000000001000000110000000000		2		2			2		2	1			30	30				
H9847	001	0	1	04	01	H9847_001_0	9	1	1	11	011110010000000110111110001100010010	011100000000000000000100	2		2			2		2	1			20	20				
H9847	001	0	1	04	01	H9847_001_0	9	7	$30	01	000000100000000000000000000000000000		2		1	30.00	30.00	2		2	2								
H9847	005	0	1	04	01	H9847_005_0	10	2	ZERO COSTSHARE	11	000000000000000000000000000011100000	000000000000000100001100	2		1	0.00	0.00	2		2	2								
H9847	005	0	1	04	01	H9847_005_0	10	3	fitness	10		000000000000000010000000	2		1	0.00	50.00	2		2	2								
H9847	005	0	1	04	01	H9847_005_0	10	4	$25	01	000000100000000000000000000000000000		2		1	25.00	25.00	2		2	2								
H9847	005	0	1	04	01	H9847_005_0	10	5	49	11	011100011111111000000000000000001101	011100000000000000000000	2		1	49.00	49.00	2		2	2								
H9847	005	0	1	04	01	H9847_005_0	10	1	COINSURANCE GROUP	11	000011000000000111111111111100010010	000000100001000001100000	2		2			2		2	1			20	20				
H9847	801	0	1	04	01	H9847_801_0	5	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H9847	801	0	1	04	01	H9847_801_0	5	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H9847	801	0	1	04	01	H9847_801_0	5	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H9847	802	0	1	04	01	H9847_802_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H9847	802	0	1	04	01	H9847_802_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H9847	802	0	1	04	01	H9847_802_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H9847	803	0	1	04	01	H9847_803_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H9847	803	0	1	04	01	H9847_803_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H9847	803	0	1	04	01	H9847_803_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H9847	804	0	1	04	01	H9847_804_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H9847	804	0	1	04	01	H9847_804_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H9847	804	0	1	04	01	H9847_804_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H9847	805	0	1	04	01	H9847_805_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H9847	805	0	1	04	01	H9847_805_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H9847	805	0	1	04	01	H9847_805_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H9847	806	0	1	04	01	H9847_806_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H9847	806	0	1	04	01	H9847_806_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H9847	806	0	1	04	01	H9847_806_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H9947	001	0	1	04	01	H9947_001_0	10	9	$0 Copayment Group	01	000000000000000000000000000010000000		2		1	0.00	0.00	2		2	2								
H9947	001	0	1	04	01	H9947_001_0	10	1	$45 Copayment Group	01	011100001101001000000000000000000001		2		1	45.00	45.00	2		2	2								
H9947	001	0	1	04	01	H9947_001_0	10	7	25% Coinsurance Group	01	000000000000000001000000000000010000		2		2			2		2	1			25	25				
H9947	001	0	1	04	01	H9947_001_0	10	6	$0 to $300 Copayment Group	01	000000000000000100000000000000000000		2		1	0.00	300.00	2		2	2								
H9947	001	0	1	04	01	H9947_001_0	10	5	$0 Copayment Group	11	000000000000000000000010001011100110	000000100000000010000000	2		1	0.00	0.00	2		2	2								
H9947	001	0	1	04	01	H9947_001_0	10	4	$80 Copayment Group	01	000010000010010000000100000000000000		2		1	80.00	80.00	2		2	2								
H9947	001	0	1	04	01	H9947_001_0	10	3	$30 Copayment Group	01	000000100000100000000000000000000000		2		1	30.00	30.00	2		2	2								
H9947	001	0	1	04	01	H9947_001_0	10	2	$40 Copayment Group	01	000000010000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H9947	001	0	1	04	01	H9947_001_0	10	15	$200 - $300 Copayment Group	01	000000000000000010000000000000000000		2		1	200.00	300.00	2		2	2								
H9947	001	0	1	04	01	H9947_001_0	10	14	0% - 25%  and $0 - $45 Group	01	000000000000000000010000000000000000		2		1	0.00	45.00	2		2	1			0	25				
H9947	001	0	1	04	01	H9947_001_0	10	13	$200 Copayment Group	01	000000000000000000100000000000000000		2		1	200.00	200.00	2		2	2								
H9947	001	0	1	04	01	H9947_001_0	10	12	10% coinsurance group	01	000001000000000000000000000000000000		2		2			2		2	1			10	10				
H9947	001	0	1	04	01	H9947_001_0	10	11	$175 Copayment Group	01	000000000000000000000001000000000000		2		1	175.00	175.00	2		2	2								
H9947	001	0	1	04	01	H9947_001_0	10	10	0% - 25%  Coinsurance Group	01	000000000000000000001000000000000000		2		2			2		2	1			0	25				
H9947	001	0	1	04	01	H9947_001_0	10	8	20% Coinsurance Group	01	000000000000000000000000110100001000		2		2			2		2	1			20	20				
H9947	002	0	1	04	01	H9947_002_0	10	8	$0 Copayment Group	11	000000000000000000000010001011100110	000000100000000010000000	2		1	0.00	0.00	2		2	2								
H9947	002	0	1	04	01	H9947_002_0	10	9	0% - 25% Coinsurance Group	01	000000000000000000001000000000000000		2		2			2		2	1			0	25				
H9947	002	0	1	04	01	H9947_002_0	10	7	20% Coinsurance Group	11	000000000000000000000000000100001000	000000000000000000100000	2		2			2		2	1			20	20				
H9947	002	0	1	04	01	H9947_002_0	10	6	35% Coinsurance Group	01	000000000000000001000000110000010000		2		2			2		2	1			35	35				
H9947	002	0	1	04	01	H9947_002_0	10	5	$0 to $500 Copayment group	01	000000000000000100000000000000000000		2		1	0.00	500.00	2		2	2								
H9947	002	0	1	04	01	H9947_002_0	10	4	10% Coinsurance Group	01	000001000000000000000000000000000000		2		2			2		2	1			10	10				
H9947	002	0	1	04	01	H9947_002_0	10	3	$30 Copayment Group	01	000000100000100000000000000000000000		2		1	30.00	30.00	2		2	2								
H9947	002	0	1	04	01	H9947_002_0	10	2	$80 Copayment Group	01	000010000010010000000100000000000000		2		1	80.00	80.00	2		2	2								
H9947	002	0	1	04	01	H9947_002_0	10	14	$200 - $500 Copayment Group	01	000000000000000010000000000000000000		2		1	200.00	500.00	2		2	2								
H9947	002	0	1	04	01	H9947_002_0	10	13	0% - 25%  and $0 - $40 Group	01	000000000000000000010000000000000000		2		1	0.00	40.00	2		2	1			0	25				
H9947	002	0	1	04	01	H9947_002_0	10	12	$200 Copayment Group	01	000000000000000000100000000000000000		2		1	200.00	200.00	2		2	2								
H9947	002	0	1	04	01	H9947_002_0	10	11	$40 Copayment Group	01	000000010000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H9947	002	0	1	04	01	H9947_002_0	10	10	$110 Copayment Group	01	000000000000000000000001000000000000		2		1	110.00	110.00	2		2	2								
H9947	002	0	1	04	01	H9947_002_0	10	1	$40 Copayment Group	01	011100001101001000000000000000000001		2		1	40.00	40.00	2		2	2								
H9947	004	0	1	04	01	H9947_004_0	11	1	$50 Copayment Group	01	011100001101001000000000000000000001		2		1	50.00	50.00	2		2	2								
H9947	004	0	1	04	01	H9947_004_0	11	9	$180 Copayment Group	01	000000000000000000000001000000000000		2		1	180.00	180.00	2		2	2								
H9947	004	0	1	04	01	H9947_004_0	11	14	30% Coinsurance Group	01	000000000000000001000000000000010000		2		2			2		2	1			30	30				
H9947	004	0	1	04	01	H9947_004_0	11	13	0% - 25% and $0 - $50 Group	01	000000000000000000010000000000000000		2		1	0.00	50.00	2		2	1			0	25				
H9947	004	0	1	04	01	H9947_004_0	11	12	$130 Copayment Group	01	000000000000000000100000000000000000		2		1	130.00	130.00	2		2	2								
H9947	004	0	1	04	01	H9947_004_0	11	11	20% Coinsurance Group	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
H9947	004	0	1	04	01	H9947_004_0	11	10	0% - 25% Coinsurance Group	01	000000000000000000001000000000000000		2		2			2		2	1			0	25				
H9947	004	0	1	04	01	H9947_004_0	11	15	$130 - $400 copayment group	01	000000000000000010000000000000000000		2		1	130.00	400.00	2		2	2								
H9947	004	0	1	04	01	H9947_004_0	11	2	$80 Copayment Group	01	000010000010010000000100000000000000		2		1	80.00	80.00	2		2	2								
H9947	004	0	1	04	01	H9947_004_0	11	3	10% Coinsurance Group	01	000001000000000000000000000000000000		2		2			2		2	1			10	10				
H9947	004	0	1	04	01	H9947_004_0	11	8	$0 Copayment Group	11	000000000000000000000010001011101110	000000100000000010000000	2		1	0.00	0.00	2		2	2								
H9947	004	0	1	04	01	H9947_004_0	11	7	35% Coinsurance Group	01	000000000000000000000000110000000000		2		2			2		2	1			35	35				
H9947	004	0	1	04	01	H9947_004_0	11	6	$0 to $400 Copayment Group	01	000000000000000100000000000000000000		2		1	0.00	400.00	2		2	2								
H9947	004	0	1	04	01	H9947_004_0	11	5	$40 Copayment Group	01	000000010000000000000000000000000000		2		1	40.00	40.00	2		2	2								
H9947	004	0	1	04	01	H9947_004_0	11	4	$30 Copayment Group	01	000000100000100000000000000000000000		2		1	30.00	30.00	2		2	2								
H9947	801	0	1	04	01	H9947_801_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H9947	801	0	1	04	01	H9947_801_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H9947	801	0	1	04	01	H9947_801_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H9947	802	0	1	04	01	H9947_802_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H9947	802	0	1	04	01	H9947_802_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H9947	802	0	1	04	01	H9947_802_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
H9947	803	0	1	04	01	H9947_803_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
H9947	803	0	1	04	01	H9947_803_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
H9947	803	0	1	04	01	H9947_803_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
R3175	001	0	1	31	11	R3175_001_0	7	1	Group 1	01	000000100000000000000000000000000000		2		1	40.00	40.00	2		2	2								
R3175	001	0	1	31	11	R3175_001_0	7	10	Group 10	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
R3175	001	0	1	31	11	R3175_001_0	7	11	Group 11	11	000000000000000000000010000000000000	000000100000000010000100	2		1	0.00	0.00	2		2	2								
R3175	001	0	1	31	11	R3175_001_0	7	12	Group 12	01	000000000000000000000000000010000000		2		2			2		2	1			0	40				
R3175	001	0	1	31	11	R3175_001_0	7	13	Group 13	01	000001000000000000000000100000000000		2		2			2		2	1			50	50				
R3175	001	0	1	31	11	R3175_001_0	7	14	Group 14	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
R3175	001	0	1	31	11	R3175_001_0	7	9	Group 9	01	000000000000100000000000000000000000		2		1	40.00	50.00	2		2	2								
R3175	001	0	1	31	11	R3175_001_0	7	3	Group 3	11	000000000000000011011000011001110010	000000000001000100000000	2		2			2		2	1			40	40				
R3175	001	0	1	31	11	R3175_001_0	7	4	Group 4	01	000000000000000100000000000000000000		2		1	18.00	18.00	2		2	1			40	40				
R3175	001	0	1	31	11	R3175_001_0	7	5	Group 5	01	000000000000000000100000000000000000		2		1	21.00	21.00	2		2	2								
R3175	001	0	1	31	11	R3175_001_0	7	6	Group 6	01	000010000000000000000000000000000000		2		1	75.00	75.00	2		2	2								
R3175	001	0	1	31	11	R3175_001_0	7	7	Group 7	01	000000000000000000000001000000000000		2		1	290.00	290.00	2		2	2								
R3175	001	0	1	31	11	R3175_001_0	7	8	Group 8	01	000000000010010000000100000000000000		2		1	35.00	45.00	2		2	2								
R3175	001	0	1	31	11	R3175_001_0	7	2	Group 2	11	011100011101001000000000000000001101	000001000000000000001010	2		1	50.00	50.00	2		2	2								
R3175	002	0	1	31	11	R3175_002_0	4	7	Group 7	01	000000000000000000000001000000000000		2		1	290.00	290.00	2		2	2								
R3175	002	0	1	31	11	R3175_002_0	4	8	Group 8	01	000000000010010000000100000000000000		2		1	35.00	45.00	2		2	2								
R3175	002	0	1	31	11	R3175_002_0	4	9	Group 9	01	000000000000100000000000000000000000		2		1	40.00	50.00	2		2	2								
R3175	002	0	1	31	11	R3175_002_0	4	1	Group 1	01	000000100000000000000000000000000000		2		1	40.00	40.00	2		2	2								
R3175	002	0	1	31	11	R3175_002_0	4	10	Group 10	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
R3175	002	0	1	31	11	R3175_002_0	4	11	Group 11	11	000000000000000000000010000000000000	000000100000000010000100	2		1	0.00	0.00	2		2	2								
R3175	002	0	1	31	11	R3175_002_0	4	12	Group 12	01	000000000000000000000000000010000000		2		2			2		2	1			0	40				
R3175	002	0	1	31	11	R3175_002_0	4	13	Group 13	01	000001000000000000000000100000000000		2		2			2		2	1			50	50				
R3175	002	0	1	31	11	R3175_002_0	4	14	Group 14	10		000000000000000000000001	2		1	110.00	160.00	2		2	2								
R3175	002	0	1	31	11	R3175_002_0	4	2	Group 2	11	011100011101001000000000000000001101	000011001000000000001010	2		1	50.00	50.00	2		2	2								
R3175	002	0	1	31	11	R3175_002_0	4	3	Group 3	11	000000000000000011011000011001110010	000000000001000100000000	2		2			2		2	1			40	40				
R3175	002	0	1	31	11	R3175_002_0	4	4	Group 4	01	000000000000000100000000000000000000		2		1	13.00	13.00	2		2	1			40	40				
R3175	002	0	1	31	11	R3175_002_0	4	5	Group 5	01	000000000000000000100000000000000000		2		1	21.00	21.00	2		2	2								
R3175	002	0	1	31	11	R3175_002_0	4	6	Group 6	01	000010000000000000000000000000000000		2		1	75.00	75.00	2		2	2								
R3175	003	0	1	31	11	R3175_003_0	7	1	Group 1	11	011111111111111011111111111001101101	000001100000000000000000	2		2			2		2	1			30	30				
R3175	003	0	1	31	11	R3175_003_0	7	2	Group 2	01	000000000000000100000000000010000000		2		2			2		2	1			0	30				
R3175	003	0	1	31	11	R3175_003_0	7	3	Group 3	11	000000000000000000000000000000000010	000000000100000010110000	2		1	0.00	0.00	2		2	2								
R3175	003	0	1	31	11	R3175_003_0	7	4	Group 4	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
R3175	003	0	1	31	11	R3175_003_0	7	5	Group 5	01	000000000000000000000000000000010000		2		2			2		2	1			21	21				
R3175	801	0	1	31	11	R3175_801_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
R3175	801	0	1	31	11	R3175_801_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
R3175	801	0	1	31	11	R3175_801_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
R3175	802	0	1	31	11	R3175_802_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
R3175	802	0	1	31	11	R3175_802_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
R3175	802	0	1	31	11	R3175_802_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
R3332	001	0	1	31	11	R3332_001_0	9	1	40% coinsurance	11	000010000000100111111010010011100000	000000100000000000000000	2		2			2		2	1			40	40				
R3332	001	0	1	31	11	R3332_001_0	9	10	Cardiac and Pulmonary Rehab	01	011100000000000000000000000000000000		2		1	50.00	50.00	2		2	1			40	40				
R3332	001	0	1	31	11	R3332_001_0	9	11	30% Coinsurance DME	01	000000000000000000000000101000000000		2		2			2		2	1			30	30				
R3332	001	0	1	31	11	R3332_001_0	9	2	50% coinsurance	01	000001000000000000000000000000010000		2		2			2		2	1			50	50				
R3332	001	0	1	31	11	R3332_001_0	9	3	Ambulance	01	000000000000000000000001000000000000		2		1	250.00	250.00	2		2	2								
R3332	001	0	1	31	11	R3332_001_0	9	9	$50 copayment	11	000000011101001000000000000000000111	000001000000000000000000	2		1	50.00	50.00	2		2	2								
R3332	001	0	1	31	11	R3332_001_0	9	5	0 copayment	10		000000000000000010001011	2		2			2		2	2								
R3332	001	0	1	31	11	R3332_001_0	9	6	Dental	11	000000000000000000000000000000001000	000000000000000000110000	2		2			2		2	1			40	50				
R3332	001	0	1	31	11	R3332_001_0	9	7	Eye wear	10		000000000000000000000100	1	125.00	1	20.00	20.00	2		2	2								
R3332	001	0	1	31	11	R3332_001_0	9	8	$40 copayment	01	000000100010010000000100000000000000		2		1	40.00	40.00	2		2	2								
R3332	001	0	1	31	11	R3332_001_0	9	4	Renal Dialysis	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
R3444	008	0	1	31	11	R3444_008_0	5	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
R3444	008	0	1	31	11	R3444_008_0	5	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
R3444	008	0	1	31	11	R3444_008_0	5	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
R3444	008	0	1	31	11	R3444_008_0	5	4	$0 Copayment	11	000001000000000000000000000011100000	000001010100000010111100	2		1	0.00	0.00	2		2	2								
R3444	008	0	1	31	11	R3444_008_0	5	5	$330 to $380 Copayment	10		000000000000000000000001	2		1	330.00	380.00	2		2	2								
R3444	009	0	1	31	11	R3444_009_0	6	1	$45 Copayment	01	011100001101101000000000000000000011		2		1	45.00	45.00	2		2	2								
R3444	009	0	1	31	11	R3444_009_0	6	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
R3444	009	0	1	31	11	R3444_009_0	6	9	$15 Copayment	01	000000000000000000100000000000000000		2		1	15.00	15.00	2		2	2								
R3444	009	0	1	31	11	R3444_009_0	6	7	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
R3444	009	0	1	31	11	R3444_009_0	6	6	$30 to $40 Copayment	01	000000000010010000000100000000000000		2		1	30.00	40.00	2		2	2								
R3444	009	0	1	31	11	R3444_009_0	6	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
R3444	009	0	1	31	11	R3444_009_0	6	4	$30 Copayment	11	000000100000000000000000000000000000	000000000000000000001000	2		1	30.00	30.00	2		2	2								
R3444	009	0	1	31	11	R3444_009_0	6	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
R3444	009	0	1	31	11	R3444_009_0	6	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
R3444	009	0	1	31	11	R3444_009_0	6	15	$14 Copayment	01	000000000000000100000000000000000000		2		1	14.00	14.00	2		2	2								
R3444	009	0	1	31	11	R3444_009_0	6	14	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
R3444	009	0	1	31	11	R3444_009_0	6	13	$0 to $45 Copayment	01	000000000000000000000000000000000100		2		1	0.00	45.00	2		2	2								
R3444	009	0	1	31	11	R3444_009_0	6	12	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
R3444	009	0	1	31	11	R3444_009_0	6	11	$0 Copayment	11	000000000000000000000010001011101000	000001110000000010000100	2		1	0.00	0.00	2		2	2								
R3444	009	0	1	31	11	R3444_009_0	6	10	$150 Copayment	01	000000000000000000011001000000000000		2		1	150.00	150.00	2		2	2								
R3444	011	0	1	31	11	R3444_011_0	5	5	$330 to $380 Copayment	10		000000000000000000000001	2		1	330.00	380.00	2		2	2								
R3444	011	0	1	31	11	R3444_011_0	5	4	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
R3444	011	0	1	31	11	R3444_011_0	5	3	$0 Copayment	11	000001000000000000000000000011100000	000000010000000010111100	2		1	0.00	0.00	2		2	2								
R3444	011	0	1	31	11	R3444_011_0	5	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
R3444	011	0	1	31	11	R3444_011_0	5	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
R3444	012	0	1	31	11	R3444_012_0	6	9	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
R3444	012	0	1	31	11	R3444_012_0	6	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
R3444	012	0	1	31	11	R3444_012_0	6	7	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
R3444	012	0	1	31	11	R3444_012_0	6	6	$35 to $40 Copayment	01	000000000010010000000100000000000000		2		1	35.00	40.00	2		2	2								
R3444	012	0	1	31	11	R3444_012_0	6	4	$35 Copayment	01	000000100000000000000000000000000000		2		1	35.00	35.00	2		2	2								
R3444	012	0	1	31	11	R3444_012_0	6	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
R3444	012	0	1	31	11	R3444_012_0	6	1	$50 Copayment	01	011100001101101000000000000000000111		2		1	50.00	50.00	2		2	2								
R3444	012	0	1	31	11	R3444_012_0	6	10	$250 Copayment	01	000000000000000000011000000000000000		2		1	250.00	250.00	2		2	2								
R3444	012	0	1	31	11	R3444_012_0	6	11	$0 Copayment	11	000000000000000000000010001011101100	000000110000000010000100	2		1	0.00	0.00	2		2	2								
R3444	012	0	1	31	11	R3444_012_0	6	12	$180 Copayment	01	000000000000000000000001000000000000		2		1	180.00	180.00	2		2	2								
R3444	012	0	1	31	11	R3444_012_0	6	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
R3444	012	0	1	31	11	R3444_012_0	6	14	$30 Copayment	10		000000000000000000001000	2		1	30.00	30.00	2		2	2								
R3444	012	0	1	31	11	R3444_012_0	6	15	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
R3444	012	0	1	31	11	R3444_012_0	6	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
R3444	012	0	1	31	11	R3444_012_0	6	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
R3444	021	0	1	31	11	R3444_021_0	5	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
R3444	021	0	1	31	11	R3444_021_0	5	4	$0 Copayment	11	000001000000000000000000000011100000	000000010100000010111100	2		1	0.00	0.00	2		2	2								
R3444	021	0	1	31	11	R3444_021_0	5	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
R3444	021	0	1	31	11	R3444_021_0	5	5	$330 to $380 Copayment	10		000000000000000000000001	2		1	330.00	380.00	2		2	2								
R3444	021	0	1	31	11	R3444_021_0	5	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
R3444	022	0	1	31	11	R3444_022_0	5	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
R3444	022	0	1	31	11	R3444_022_0	5	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
R3444	022	0	1	31	11	R3444_022_0	5	14	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
R3444	022	0	1	31	11	R3444_022_0	5	13	$0 to $45 Copayment	01	000000000000000000000000000000000100		2		1	0.00	45.00	2		2	2								
R3444	022	0	1	31	11	R3444_022_0	5	12	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
R3444	022	0	1	31	11	R3444_022_0	5	11	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
R3444	022	0	1	31	11	R3444_022_0	5	10	$150 Copayment	01	000000000000000000011001000000000000		2		1	150.00	150.00	2		2	2								
R3444	022	0	1	31	11	R3444_022_0	5	1	$45 Copayment	01	011100001101101000000000000000000011		2		1	45.00	45.00	2		2	2								
R3444	022	0	1	31	11	R3444_022_0	5	4	$30 Copayment	11	000000100000000000000000000000000000	000000000000000000001000	2		1	30.00	30.00	2		2	2								
R3444	022	0	1	31	11	R3444_022_0	5	9	$15 Copayment	01	000000000000000100100000000000000000		2		1	15.00	15.00	2		2	2								
R3444	022	0	1	31	11	R3444_022_0	5	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
R3444	022	0	1	31	11	R3444_022_0	5	7	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
R3444	022	0	1	31	11	R3444_022_0	5	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
R3444	022	0	1	31	11	R3444_022_0	5	6	$30 to $40 Copayment	01	000000000010010000000100000000000000		2		1	30.00	40.00	2		2	2								
R5287	001	0	1	31	11	R5287_001_0	6	10	Group 10	01	000001000000000000000000100000010000		2		2			2		2	1			50	50				
R5287	001	0	1	31	11	R5287_001_0	6	1	Group 1	11	011100011101001000000000000000001101	000001000000000000001010	2		1	45.00	45.00	2		2	2								
R5287	001	0	1	31	11	R5287_001_0	6	11	Group 11	01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
R5287	001	0	1	31	11	R5287_001_0	6	12	Group 12	11	000000100000000000000000000000000000	000000000000000000100000	2		1	40.00	40.00	2		2	2								
R5287	001	0	1	31	11	R5287_001_0	6	13	Group 13	01	000000000000100000000000000000000000		2		1	40.00	45.00	2		2	2								
R5287	001	0	1	31	11	R5287_001_0	6	14	Group 14	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
R5287	001	0	1	31	11	R5287_001_0	6	9	Group 9	11	000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2	2								
R5287	001	0	1	31	11	R5287_001_0	6	3	Group 3	01	000000000000000100000000000000000000		2		1	14.00	14.00	2		2	1			30	30				
R5287	001	0	1	31	11	R5287_001_0	6	4	Group 4	01	000000000000000000100000000000000000		2		1	21.00	21.00	2		2	2								
R5287	001	0	1	31	11	R5287_001_0	6	5	Group 5	01	000010000000000000000000000000000000		2		1	75.00	75.00	2		2	2								
R5287	001	0	1	31	11	R5287_001_0	6	6	Group 6	01	000000000000000000000001000000000000		2		1	280.00	280.00	2		2	2								
R5287	001	0	1	31	11	R5287_001_0	6	7	Group 7	01	000000000010010000000100000000000000		2		1	35.00	45.00	2		2	2								
R5287	001	0	1	31	11	R5287_001_0	6	8	Group 8	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
R5287	001	0	1	31	11	R5287_001_0	6	2	Group 2	11	000000000000000011011000011001100010	000000000001000100000000	2		2			2		2	1			30	30				
R5287	002	0	1	31	11	R5287_002_0	3	10	Group 10	01	000001000000000000000000100000010000		2		2			2		2	1			50	50				
R5287	002	0	1	31	11	R5287_002_0	3	1	Group 1	11	011100011101001000000000000000001101	000001000000000000001010	2		1	45.00	45.00	2		2	2								
R5287	002	0	1	31	11	R5287_002_0	3	11	Group 11	01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
R5287	002	0	1	31	11	R5287_002_0	3	9	Group 9	11	000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2	2								
R5287	002	0	1	31	11	R5287_002_0	3	8	Group 8	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
R5287	002	0	1	31	11	R5287_002_0	3	7	Group 7	01	000000000010010000000100000000000000		2		1	35.00	45.00	2		2	2								
R5287	002	0	1	31	11	R5287_002_0	3	6	Group 6	01	000000000000000000000001000000000000		2		1	225.00	225.00	2		2	2								
R5287	002	0	1	31	11	R5287_002_0	3	5	Group 5	01	000010000000000000000000000000000000		2		1	75.00	75.00	2		2	2								
R5287	002	0	1	31	11	R5287_002_0	3	12	Group 12	11	000000100000000000000000000000000000	000000000000000000100000	2		1	40.00	40.00	2		2	2								
R5287	002	0	1	31	11	R5287_002_0	3	13	Group 13	01	000000000000100000000000000000000000		2		1	40.00	45.00	2		2	2								
R5287	002	0	1	31	11	R5287_002_0	3	14	Group 14	10		000000000000000000000001	2		1	330.00	380.00	2		2	2								
R5287	002	0	1	31	11	R5287_002_0	3	2	Group 2	11	000000000000000011011000011001100010	000000000001000100000000	2		2			2		2	1			30	30				
R5287	002	0	1	31	11	R5287_002_0	3	3	Group 3	01	000000000000000100000000000000000000		2		1	10.00	10.00	2		2	1			30	30				
R5287	002	0	1	31	11	R5287_002_0	3	4	Group 4	01	000000000000000000100000000000000000		2		1	21.00	21.00	2		2	2								
R5287	003	0	1	31	11	R5287_003_0	5	4	Group 4	11	000000000000000000000000000000000010	000000000100000000000100	2		1	0.00	0.00	2		2	2								
R5287	003	0	1	31	11	R5287_003_0	5	3	Group 3	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
R5287	003	0	1	31	11	R5287_003_0	5	2	Group 2	01	000000000000000100000000000010000000		2		2			2		2	1			0	30				
R5287	003	0	1	31	11	R5287_003_0	5	1	Group 1	11	011111111111111011111111111001111101	000001100000000000001000	2		2			2		2	1			30	30				
R5287	003	0	1	31	11	R5287_003_0	5	5	Group 5	10		000000000000000000100000	2		1	40.00	40.00	2		2	2								
R5287	003	0	1	31	11	R5287_003_0	5	6	Group 6	10		000000010000000000000000	2		2			2		2	1			75	75				
R5342	001	0	1	31	11	R5342_001_0	6	12	Group 12	01	000001000000000000000000100000000000		2		2			2		2	1			50	50				
R5342	001	0	1	31	11	R5342_001_0	6	11	Group 11	01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
R5342	001	0	1	31	11	R5342_001_0	6	10	Group 10	11	000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2	2								
R5342	001	0	1	31	11	R5342_001_0	6	1	Group 1	01	000000100000000000000000000000000000		2		1	20.00	20.00	2		2	2								
R5342	001	0	1	31	11	R5342_001_0	6	13	Group 13	01	000000000000100000000000000000000000		2		1	20.00	40.00	2		2	2								
R5342	001	0	1	31	11	R5342_001_0	6	14	Group 14	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
R5342	001	0	1	31	11	R5342_001_0	6	9	Group 9	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
R5342	001	0	1	31	11	R5342_001_0	6	3	Group 3	11	000000000000000011011000011001110010	000000000001000100000000	2		2			2		2	1			30	30				
R5342	001	0	1	31	11	R5342_001_0	6	4	Group 4	01	000000000000000100000000000000000000		2		1	13.00	13.00	2		2	1			30	30				
R5342	001	0	1	31	11	R5342_001_0	6	5	Group 5	01	000000000000000000100000000000000000		2		1	21.00	21.00	2		2	2								
R5342	001	0	1	31	11	R5342_001_0	6	6	Group 6	01	000010000000000000000000000000000000		2		1	75.00	75.00	2		2	2								
R5342	001	0	1	31	11	R5342_001_0	6	7	Group 7	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
R5342	001	0	1	31	11	R5342_001_0	6	8	Group 8	01	000000000010010000000100000000000000		2		1	35.00	45.00	2		2	2								
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R5826	836	0	1	31	11	R5826_836_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
R5826	836	0	1	31	11	R5826_836_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
R5826	837	0	1	31	11	R5826_837_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
R5826	837	0	1	31	11	R5826_837_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
R5826	837	0	1	31	11	R5826_837_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
R5826	838	0	1	31	11	R5826_838_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
R5826	838	0	1	31	11	R5826_838_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
R5826	838	0	1	31	11	R5826_838_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
R5826	839	0	1	31	11	R5826_839_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
R5826	839	0	1	31	11	R5826_839_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
R5826	839	0	1	31	11	R5826_839_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
R5826	840	0	1	31	11	R5826_840_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
R5826	840	0	1	31	11	R5826_840_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
R5826	840	0	1	31	11	R5826_840_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
R5826	841	0	1	31	11	R5826_841_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
R5826	841	0	1	31	11	R5826_841_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
R5826	841	0	1	31	11	R5826_841_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
R5826	842	0	1	31	11	R5826_842_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
R5826	842	0	1	31	11	R5826_842_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
R5826	842	0	1	31	11	R5826_842_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
R5826	843	0	1	31	11	R5826_843_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
R5826	843	0	1	31	11	R5826_843_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
R5826	843	0	1	31	11	R5826_843_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
R5826	844	0	1	31	11	R5826_844_0	3	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
R5826	844	0	1	31	11	R5826_844_0	3	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
R5826	844	0	1	31	11	R5826_844_0	3	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
R5941	007	0	1	31	11	R5941_007_0	12	8	$50	01	000010000010010000000100000000000000		2		1	50.00	50.00	2		2	2								
R5941	007	0	1	31	11	R5941_007_0	12	7	$45	11	000000011101001000000000000000000001	000000000000000000000010	2		1	45.00	45.00	2		2	2								
R5941	007	0	1	31	11	R5941_007_0	12	9	$150	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
R5941	007	0	1	31	11	R5941_007_0	12	6	$30	01	000000100000100000000000000000000000		2		1	30.00	30.00	2		2	2								
R5941	007	0	1	31	11	R5941_007_0	12	5	$30 - $45 - 30%	01	000000000000000000010000000000000000		2		1	30.00	45.00	2		2	1			30	30				
R5941	007	0	1	31	11	R5941_007_0	12	4	30%	01	000000000000000000001000000000000000		2		2			2		2	1			30	30				
R5941	007	0	1	31	11	R5941_007_0	12	3	$0 - $25 - 30%	01	000000000000000100000000000000000000		2		1	0.00	25.00	2		2	1			30	30				
R5941	007	0	1	31	11	R5941_007_0	12	2	30%	01	000000000000000010100000111000000000		2		2			2		2	1			30	30				
R5941	007	0	1	31	11	R5941_007_0	12	11	$0 - $45	01	000000000000000000000000000000000100		2		1	0.00	45.00	2		2	2								
R5941	007	0	1	31	11	R5941_007_0	12	10	$0	11	011101000000000000000010000011101010	000000100000000010001100	2		1	0.00	0.00	2		2	2								
R5941	007	0	1	31	11	R5941_007_0	12	1	20%	11	000000000000000001000000000100010000	000000000000000000100000	2		2			2		2	1			20	20				
R5941	008	0	1	31	11	R5941_008_0	16	8	$50	01	000010000010010000000100000000000000		2		1	50.00	50.00	2		2	2								
R5941	008	0	1	31	11	R5941_008_0	16	1	20%	11	000000000000000001000000000100010000	000000000000000000100000	2		2			2		2	1			20	20				
R5941	008	0	1	31	11	R5941_008_0	16	9	$125	01	000000000000000000000001000000000000		2		1	125.00	125.00	2		2	2								
R5941	008	0	1	31	11	R5941_008_0	16	10	$0	11	011101000000000000000010000011101010	000000100000000010001100	2		1	0.00	0.00	2		2	2								
R5941	008	0	1	31	11	R5941_008_0	16	11	$0 - $45	01	000000000000000000000000000000000100		2		1	0.00	45.00	2		2	2								
R5941	008	0	1	31	11	R5941_008_0	16	2	30%	01	000000000000000000001000111000000000		2		2			2		2	1			30	30				
R5941	008	0	1	31	11	R5941_008_0	16	3	$0 -$20- 25%	01	000000000000000100000000000000000000		2		1	0.00	20.00	2		2	1			25	25				
R5941	008	0	1	31	11	R5941_008_0	16	4	25%	01	000000000000000010100000000000000000		2		2			2		2	1			25	25				
R5941	008	0	1	31	11	R5941_008_0	16	5	$30 - $45 - 30%	01	000000000000000000010000000000000000		2		1	30.00	45.00	2		2	1			30	30				
R5941	008	0	1	31	11	R5941_008_0	16	6	$30	01	000000100000100000000000000000000000		2		1	30.00	30.00	2		2	2								
R5941	008	0	1	31	11	R5941_008_0	16	7	$45	11	000000011101001000000000000000000001	000000000000000000000010	2		1	45.00	45.00	2		2	2								
R5941	009	0	1	31	11	R5941_009_0	15	8	$50	01	000010000010010000000100000000000000		2		1	50.00	50.00	2		2	2								
R5941	009	0	1	31	11	R5941_009_0	15	9	$150	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
R5941	009	0	1	31	11	R5941_009_0	15	7	$50	11	000000001101001000000000000000000001	000000000000000000000010	2		1	50.00	50.00	2		2	2								
R5941	009	0	1	31	11	R5941_009_0	15	6	$30	01	000000110000100000000000000000000000		2		1	30.00	30.00	2		2	2								
R5941	009	0	1	31	11	R5941_009_0	15	5	$30 - $50 - 25%	01	000000000000000000010000000000000000		2		1	30.00	50.00	2		2	1			25	25				
R5941	009	0	1	31	11	R5941_009_0	15	1	20%	01	000000000000000001000000000100010000		2		2			2		2	1			20	20				
R5941	009	0	1	31	11	R5941_009_0	15	3	$0 - $20- 30%	01	000000000000000100000000000000000000		2		1	0.00	20.00	2		2	1			30	30				
R5941	009	0	1	31	11	R5941_009_0	15	2	30%	01	000000000000000010100000111000000000		2		2			2		2	1			30	30				
R5941	009	0	1	31	11	R5941_009_0	15	11	$0 - $50	01	000000000000000000000000000000000100		2		1	0.00	50.00	2		2	2								
R5941	009	0	1	31	11	R5941_009_0	15	10	$0	11	011101000000000000000010000011101010	000000100000000010000000	2		1	0.00	0.00	2		2	2								
R5941	009	0	1	31	11	R5941_009_0	15	4	25%	01	000000000000000000001000000000000000		2		2			2		2	1			25	25				
R6801	008	0	1	31	11	R6801_008_0	4	5	$330 to $380 Copayment	10		000000000000000000000001	2		1	330.00	380.00	2		2	2								
R6801	008	0	1	31	11	R6801_008_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
R6801	008	0	1	31	11	R6801_008_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
R6801	008	0	1	31	11	R6801_008_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
R6801	008	0	1	31	11	R6801_008_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000001010100000010111100	2		1	0.00	0.00	2		2	2								
R6801	009	0	1	31	11	R6801_009_0	5	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
R6801	009	0	1	31	11	R6801_009_0	5	6	$15 to $40 Copayment	01	000000000010010000000100000000000000		2		1	15.00	40.00	2		2	2								
R6801	009	0	1	31	11	R6801_009_0	5	7	$10 Copayment	11	000000000000000100000000000000000000	000000000000000000101000	2		1	10.00	10.00	2		2	2								
R6801	009	0	1	31	11	R6801_009_0	5	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
R6801	009	0	1	31	11	R6801_009_0	5	9	$15 Copayment	01	000000100000000000100000000000000000		2		1	15.00	15.00	2		2	2								
R6801	009	0	1	31	11	R6801_009_0	5	4	$330 to $380 Copayment	10		000000000000000000000001	2		1	330.00	380.00	2		2	2								
R6801	009	0	1	31	11	R6801_009_0	5	1	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
R6801	009	0	1	31	11	R6801_009_0	5	10	$150 Copayment	01	000000000000000000011001000000000000		2		1	150.00	150.00	2		2	2								
R6801	009	0	1	31	11	R6801_009_0	5	11	$0 Copayment	11	000000000000000000000010001011101000	000001110000000010000100	2		1	0.00	0.00	2		2	2								
R6801	009	0	1	31	11	R6801_009_0	5	12	$0 to $40 Copayment	01	000000000000000000000000000000000100		2		1	0.00	40.00	2		2	2								
R6801	009	0	1	31	11	R6801_009_0	5	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
R6801	009	0	1	31	11	R6801_009_0	5	2	$40 Copayment	01	011110001101101000000000000000000011		2		1	40.00	40.00	2		2	2								
R6801	011	0	1	31	11	R6801_011_0	4	5	$330 to $380 Copayment	10		000000000000000000000001	2		1	330.00	380.00	2		2	2								
R6801	011	0	1	31	11	R6801_011_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
R6801	011	0	1	31	11	R6801_011_0	4	3	$0 Copayment	11	000001000000000000000000000011100000	000000010100000010111100	2		1	0.00	0.00	2		2	2								
R6801	011	0	1	31	11	R6801_011_0	4	4	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
R6801	011	0	1	31	11	R6801_011_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
R6801	012	0	1	31	11	R6801_012_0	5	9	$150 Copayment	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
R6801	012	0	1	31	11	R6801_012_0	5	8	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
R6801	012	0	1	31	11	R6801_012_0	5	7	$15 Copayment	01	000000100000000000100000000000000000		2		1	15.00	15.00	2		2	2								
R6801	012	0	1	31	11	R6801_012_0	5	6	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
R6801	012	0	1	31	11	R6801_012_0	5	5	$10 Copayment	11	000000000000000100000000000000000000	000000000000000000101000	2		1	10.00	10.00	2		2	2								
R6801	012	0	1	31	11	R6801_012_0	5	3	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
R6801	012	0	1	31	11	R6801_012_0	5	4	$15 to $40 Copayment	01	000000000010010000000100000000000000		2		1	15.00	40.00	2		2	2								
R6801	012	0	1	31	11	R6801_012_0	5	2	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
R6801	012	0	1	31	11	R6801_012_0	5	13	$225 Copayment	01	000000000000000000011000000000000000		2		1	225.00	225.00	2		2	2								
R6801	012	0	1	31	11	R6801_012_0	5	12	$330 to $380 Copayment	10		000000000000000000000001	2		1	330.00	380.00	2		2	2								
R6801	012	0	1	31	11	R6801_012_0	5	11	$0 to $40 Copayment	01	000000000000000000000000000000000100		2		1	0.00	40.00	2		2	2								
R6801	012	0	1	31	11	R6801_012_0	5	10	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
R6801	012	0	1	31	11	R6801_012_0	5	1	$40 Copayment	01	011110001101101000000000000000000011		2		1	40.00	40.00	2		2	2								
R6801	021	0	1	31	11	R6801_021_0	4	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
R6801	021	0	1	31	11	R6801_021_0	4	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
R6801	021	0	1	31	11	R6801_021_0	4	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
R6801	021	0	1	31	11	R6801_021_0	4	5	$330 to $380 Copayment	10		000000000000000000000001	2		1	330.00	380.00	2		2	2								
R6801	021	0	1	31	11	R6801_021_0	4	4	$0 Copayment	11	000001000000000000000000000011100000	000000010100000010111100	2		1	0.00	0.00	2		2	2								
R6801	022	0	1	31	11	R6801_022_0	4	11	$0 Copayment	11	000000000000000000000010001011101000	000000110000000010000100	2		1	0.00	0.00	2		2	2								
R6801	022	0	1	31	11	R6801_022_0	4	10	$150 Copayment	01	000000000000000000011001000000000000		2		1	150.00	150.00	2		2	2								
R6801	022	0	1	31	11	R6801_022_0	4	1	$50 Copayment	01	011100001101101000000000000000000011		2		1	50.00	50.00	2		2	2								
R6801	022	0	1	31	11	R6801_022_0	4	6	$15 to $40 Copayment	01	000000000010010000000100000000000000		2		1	15.00	40.00	2		2	2								
R6801	022	0	1	31	11	R6801_022_0	4	7	$10 Copayment	11	000000000000000100000000000000000000	000000000000000000101000	2		1	10.00	10.00	2		2	2								
R6801	022	0	1	31	11	R6801_022_0	4	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
R6801	022	0	1	31	11	R6801_022_0	4	9	$15 Copayment	01	000000100000000000100000000000000000		2		1	15.00	15.00	2		2	2								
R6801	022	0	1	31	11	R6801_022_0	4	12	$0 to $50 Copayment	01	000000000000000000000000000000000100		2		1	0.00	50.00	2		2	2								
R6801	022	0	1	31	11	R6801_022_0	4	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
R6801	022	0	1	31	11	R6801_022_0	4	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
R6801	022	0	1	31	11	R6801_022_0	4	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
R6801	022	0	1	31	11	R6801_022_0	4	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
R6801	022	0	1	31	11	R6801_022_0	4	4	$330 to $380 Copayment	10		000000000000000000000001	2		1	330.00	380.00	2		2	2								
R7439	001	0	1	31	11	R7439_001_0	7	1	Group 1 - 30%	01	000001000000000011011000110000010000		2		2			2		2	1			30	30				
R7439	001	0	1	31	11	R7439_001_0	7	2	Group 2 - $30	01	000000000000000000100000000000000000		2		1	30.00	30.00	2		2	2								
R7439	001	0	1	31	11	R7439_001_0	7	3	Group 3 - $0-$15	01	000000000000000100000000000000000000		2		1	0.00	15.00	2		2	2								
R7439	001	0	1	31	11	R7439_001_0	7	4	Group 4 - $35-$50	01	000000000010010000000100000000000000		2		1	35.00	50.00	2		2	2								
R7439	001	0	1	31	11	R7439_001_0	7	6	Group 6 - $50	01	011110111101101000000000000000001101		2		1	50.00	50.00	2		2	2								
R7439	001	0	1	31	11	R7439_001_0	7	9	Group 9 - 0%-30%	01	000000000000000000000000001000000000		2		2			2		2	1			0	30				
R7439	001	0	1	31	11	R7439_001_0	7	8	Group 8 - 20%	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
R7439	001	0	1	31	11	R7439_001_0	7	7	Group 7 - $0	01	000000000000000000000010000011100010		2		1	0.00	0.00	2		2	2								
R7439	001	0	1	31	11	R7439_001_0	7	5	Group 5 - $150	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
R7439	003	0	1	31	11	R7439_003_0	9	6	Group 6 - 25%	01	000000000000000000000000100000010000		2		2			2		2	1			25	25				
R7439	003	0	1	31	11	R7439_003_0	9	5	Group 5 - $0-$30	01	000000000000000100000000000000000000		2		1	0.00	30.00	2		2	2								
R7439	003	0	1	31	11	R7439_003_0	9	4	Group 4 - $0	01	000000000000000001000010011111100010		2		1	0.00	0.00	2		2	2								
R7439	003	0	1	31	11	R7439_003_0	9	3	Group 3 - $100	01	000000000000000000011001000000000000		2		1	100.00	100.00	2		2	2								
R7439	003	0	1	31	11	R7439_003_0	9	1	Group 1 - 30%	01	000001000000000000000000000000000000		2		2			2		2	1			30	30				
R7439	003	0	1	31	11	R7439_003_0	9	2	Group 2 - $30	01	011110111111111010100100000000001101		2		1	30.00	30.00	2		2	2								
R7439	006	0	1	31	11	R7439_006_0	9	6	Group 6 - 25%	01	000000000000000000000000100000010000		2		2			2		2	1			25	25				
R7439	006	0	1	31	11	R7439_006_0	9	1	Group 1 - 30%	01	000001000000000000000000000000000000		2		2			2		2	1			30	30				
R7439	006	0	1	31	11	R7439_006_0	9	2	Group 2 - $30	01	011110111111111010100100000000001101		2		1	30.00	30.00	2		2	2								
R7439	006	0	1	31	11	R7439_006_0	9	3	Group 3 - $100	01	000000000000000000011001000000000000		2		1	100.00	100.00	2		2	2								
R7439	006	0	1	31	11	R7439_006_0	9	4	Group 4 - $0	01	000000000000000001000010011111100010		2		1	0.00	0.00	2		2	2								
R7439	006	0	1	31	11	R7439_006_0	9	5	Group 5 - $0-$30	01	000000000000000100000000000000000000		2		1	0.00	30.00	2		2	2								
R7439	801	0	1	31	11	R7439_801_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
R7439	801	0	1	31	11	R7439_801_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
R7439	801	0	1	31	11	R7439_801_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
R7439	802	0	1	31	11	R7439_802_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
R7439	802	0	1	31	11	R7439_802_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
R7439	802	0	1	31	11	R7439_802_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
R7439	805	0	1	31	11	R7439_805_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
R7439	805	0	1	31	11	R7439_805_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
R7439	805	0	1	31	11	R7439_805_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
R7439	806	0	1	31	11	R7439_806_0	4	3		01	011110111101101111111111111101111111		2		2			2		2	1			20	20				
R7439	806	0	1	31	11	R7439_806_0	4	2		01	000000000010010000000000000000000000		2		2			2		2	1			35	35				
R7439	806	0	1	31	11	R7439_806_0	4	1		01	000001000000000000000000000010000000		2		2			2		2	1			0	0				
R7444	001	0	1	31	11	R7444_001_0	7	9	Group 9	01	000000000000000000000000000010000000		2		2			2		2	1			0	30				
R7444	001	0	1	31	11	R7444_001_0	7	7	Group 7	01	000010000000000000000000000000000000		2		1	75.00	75.00	2		2	2								
R7444	001	0	1	31	11	R7444_001_0	7	6	Group 6	01	000000000010010000000100000000000000		2		1	35.00	45.00	2		2	2								
R7444	001	0	1	31	11	R7444_001_0	7	5	Group 5	01	000000000000000100000000000000000000		2		1	13.00	13.00	2		2	1			30	30				
R7444	001	0	1	31	11	R7444_001_0	7	8	Group 8	01	000000000000000000000001000000000000		2		1	200.00	200.00	2		2	2								
R7444	001	0	1	31	11	R7444_001_0	7	3	Group 3	01	000001000000000000000000100000000000		2		2			2		2	1			50	50				
R7444	001	0	1	31	11	R7444_001_0	7	2	Group 2	11	000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2	2								
R7444	001	0	1	31	11	R7444_001_0	7	10	Group 10	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
R7444	001	0	1	31	11	R7444_001_0	7	1	Group 1	11	011100111101101011111000011001111111	000001000001000100001010	2		2			2		2	1			30	30				
R7444	001	0	1	31	11	R7444_001_0	7	4	Group 4	01	000000000000000000000000000100000000		2		2			2		2	1			20	20				
R9896	008	0	1	31	11	R9896_008_0	5	4	$0 Copayment	11	000001000000000000000000000011100000	000001010100000010111100	2		1	0.00	0.00	2		2	2								
R9896	008	0	1	31	11	R9896_008_0	5	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
R9896	008	0	1	31	11	R9896_008_0	5	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
R9896	008	0	1	31	11	R9896_008_0	5	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
R9896	008	0	1	31	11	R9896_008_0	5	5	$330 to $380 Copayment	10		000000000000000000000001	2		1	330.00	380.00	2		2	2								
R9896	009	0	1	31	11	R9896_009_0	5	12	$150 Copayment	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
R9896	009	0	1	31	11	R9896_009_0	5	11	$0 Copayment	11	000000000000000000000010001011101100	000001110000000010000100	2		1	0.00	0.00	2		2	2								
R9896	009	0	1	31	11	R9896_009_0	5	10	$175 Copayment	01	000000000000000000011000000000000000		2		1	175.00	175.00	2		2	2								
R9896	009	0	1	31	11	R9896_009_0	5	1	$45 Copayment	01	011100001101101000000000000000000111		2		1	45.00	45.00	2		2	2								
R9896	009	0	1	31	11	R9896_009_0	5	9	$15 Copayment	01	000000000000000000100000000000000000		2		1	15.00	15.00	2		2	2								
R9896	009	0	1	31	11	R9896_009_0	5	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
R9896	009	0	1	31	11	R9896_009_0	5	7	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
R9896	009	0	1	31	11	R9896_009_0	5	6	$25 to $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
R9896	009	0	1	31	11	R9896_009_0	5	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
R9896	009	0	1	31	11	R9896_009_0	5	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
R9896	009	0	1	31	11	R9896_009_0	5	14	$11 Copayment	01	000000000000000100000000000000000000		2		1	11.00	11.00	2		2	2								
R9896	009	0	1	31	11	R9896_009_0	5	15	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
R9896	009	0	1	31	11	R9896_009_0	5	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
R9896	009	0	1	31	11	R9896_009_0	5	4	$25 Copayment	11	000000100000000000000000000000000000	000000000000000000001000	2		1	25.00	25.00	2		2	2								
R9896	009	0	1	31	11	R9896_009_0	5	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
R9896	012	0	1	31	11	R9896_012_0	6	14	$25 Copayment	10		000000000000000000001000	2		1	25.00	25.00	2		2	2								
R9896	012	0	1	31	11	R9896_012_0	6	15	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
R9896	012	0	1	31	11	R9896_012_0	6	2	$40 Copayment	01	000010000010010000000100000000000000		2		1	40.00	40.00	2		2	2								
R9896	012	0	1	31	11	R9896_012_0	6	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
R9896	012	0	1	31	11	R9896_012_0	6	4	$30 Copayment	01	000000100010010000000100000000000000		2		1	30.00	30.00	2		2	2								
R9896	012	0	1	31	11	R9896_012_0	6	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
R9896	012	0	1	31	11	R9896_012_0	6	6	$14 Copayment	01	000000000000000100000000000000000000		2		1	14.00	14.00	2		2	2								
R9896	012	0	1	31	11	R9896_012_0	6	7	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
R9896	012	0	1	31	11	R9896_012_0	6	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
R9896	012	0	1	31	11	R9896_012_0	6	9	$15 Copayment	01	000000000000000000100000000000000000		2		1	15.00	15.00	2		2	2								
R9896	012	0	1	31	11	R9896_012_0	6	12	$100 Copayment	01	000000000000000000000001000000000000		2		1	100.00	100.00	2		2	2								
R9896	012	0	1	31	11	R9896_012_0	6	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
R9896	012	0	1	31	11	R9896_012_0	6	11	$0 Copayment	11	000000000000000000000010001011101100	000000110000000010000100	2		1	0.00	0.00	2		2	2								
R9896	012	0	1	31	11	R9896_012_0	6	10	$250 Copayment	01	000000000000000000011000000000000000		2		1	250.00	250.00	2		2	2								
R9896	012	0	1	31	11	R9896_012_0	6	1	$45 Copayment	01	011100001101101000000000000000000111		2		1	45.00	45.00	2		2	2								
R9896	021	0	1	31	11	R9896_021_0	5	5	$330 to $380 Copayment	10		000000000000000000000001	2		1	330.00	380.00	2		2	2								
R9896	021	0	1	31	11	R9896_021_0	5	4	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
R9896	021	0	1	31	11	R9896_021_0	5	3	$0 Copayment	11	000001000000000000000000000011100000	000000010000000010111100	2		1	0.00	0.00	2		2	2								
R9896	021	0	1	31	11	R9896_021_0	5	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
R9896	021	0	1	31	11	R9896_021_0	5	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
R9896	022	0	1	31	11	R9896_022_0	5	4	$0 Copayment	11	000001000000000000000000000011100000	000000010100000010111100	2		1	0.00	0.00	2		2	2								
R9896	022	0	1	31	11	R9896_022_0	5	5	$330 to $380 Copayment	10		000000000000000000000001	2		1	330.00	380.00	2		2	2								
R9896	022	0	1	31	11	R9896_022_0	5	3	0% to 20% Coinsurance	01	000000000000000000000000000000000100		2		2			2		2	1			0	20				
R9896	022	0	1	31	11	R9896_022_0	5	2	40% Coinsurance	01	000000000010010000000100000000000000		2		2			2		2	1			40	40				
R9896	022	0	1	31	11	R9896_022_0	5	1	20% Coinsurance	01	011110111101101111111011111100011011		2		2			2		2	1			20	20				
R9896	023	0	1	31	11	R9896_023_0	5	4	$25 Copayment	11	000000100000000000000000000000000000	000000000000000000001000	2		1	25.00	25.00	2		2	2								
R9896	023	0	1	31	11	R9896_023_0	5	9	$15 Copayment	01	000000000000000000100000000000000000		2		1	15.00	15.00	2		2	2								
R9896	023	0	1	31	11	R9896_023_0	5	2	$40 Copayment	01	000010000000000000000000000000000000		2		1	40.00	40.00	2		2	2								
R9896	023	0	1	31	11	R9896_023_0	5	15	$340 to $390 Copayment	10		000000000000000000000001	2		1	340.00	390.00	2		2	2								
R9896	023	0	1	31	11	R9896_023_0	5	14	$12 Copayment	01	000000000000000100000000000000000000		2		1	12.00	12.00	2		2	2								
R9896	023	0	1	31	11	R9896_023_0	5	13	35% Coinsurance	01	000000000000000000000000100000000000		2		2			2		2	1			35	35				
R9896	023	0	1	31	11	R9896_023_0	5	12	$150 Copayment	01	000000000000000000000001000000000000		2		1	150.00	150.00	2		2	2								
R9896	023	0	1	31	11	R9896_023_0	5	11	$0 Copayment	11	000000000000000000000010001011101100	000000110000000010000100	2		1	0.00	0.00	2		2	2								
R9896	023	0	1	31	11	R9896_023_0	5	10	$175 Copayment	01	000000000000000000011000000000000000		2		1	175.00	175.00	2		2	2								
R9896	023	0	1	31	11	R9896_023_0	5	1	$45 Copayment	01	011100001101101000000000000000000111		2		1	45.00	45.00	2		2	2								
R9896	023	0	1	31	11	R9896_023_0	5	5	$20 Copayment	01	000000010000000000000000000000000000		2		1	20.00	20.00	2		2	2								
R9896	023	0	1	31	11	R9896_023_0	5	6	$25 to $40 Copayment	01	000000000010010000000100000000000000		2		1	25.00	40.00	2		2	2								
R9896	023	0	1	31	11	R9896_023_0	5	7	$10 Copayment	10		000000000000000000100000	2		1	10.00	10.00	2		2	2								
R9896	023	0	1	31	11	R9896_023_0	5	8	20% Coinsurance	01	000000000000000011000000010100010000		2		2			2		2	1			20	20				
R9896	023	0	1	31	11	R9896_023_0	5	3	40% Coinsurance	01	000001000000000000000000000000000000		2		2			2		2	1			40	40				
