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_cs_coins_yn	pbp_c_oon_outpt_coins_yn	pbp_c_oon_outpt_cs_coins_min	pbp_c_oon_outpt_coins_min_pct	pbp_c_oon_outpt_cs_coins_max	pbp_c_oon_outpt_coins_max_pct	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	4	11	Group 11	01	0000000000000000000000000000000000100		2		1	0.00	50.00	2		2		2							
H0084	001	0	1	04	01	H0084_001_0	4	9	Group 9	01	0000000000000000000011000011100010000		2		2			2		2		1		20		20			
H0084	001	0	1	04	01	H0084_001_0	4	1	Group 1	11	0111000001010000000000000000000001001	000001000000000000000000	2		1	50.00	50.00	2		2		2							
H0084	001	0	1	04	01	H0084_001_0	4	12	Group 12	11	0000000000000000000000010000011100010	000000100000000110010000	2		1	0.00	0.00	2		2		2							
H0084	001	0	1	04	01	H0084_001_0	4	13	Group 13	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H0084	001	0	1	04	01	H0084_001_0	4	14	Group 14	01	0000000000001000000000000000000000000		2		1	25.00	50.00	2		2		2							
H0084	001	0	1	04	01	H0084_001_0	4	15	Group 15	01	0000000000000000000000000100000000000		2		2			2		2		1		35		35			
H0084	001	0	1	04	01	H0084_001_0	4	2	Group 2	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
H0084	001	0	1	04	01	H0084_001_0	4	3	Group 3	01	0000010000000000000000000000000000000		2		2			2		2		1		40		40			
H0084	001	0	1	04	01	H0084_001_0	4	4	Group 4	11	0000001000000000000000000000000000000	000000000000000000001010	2		1	25.00	25.00	2		2		2							
H0084	001	0	1	04	01	H0084_001_0	4	5	Group 5	10		000000000000000000000100	1	100.00	1	0.00	0.00	2		2		2							
H0084	001	0	1	04	01	H0084_001_0	4	6	Group 6	11	0000000100000000000000000000000000000	000000000000000000100000	2		1	20.00	20.00	2		2		2							
H0084	001	0	1	04	01	H0084_001_0	4	7	Group 7	01	0000000010100110000000100000000000000		2		1	30.00	40.00	2		2		2							
H0084	001	0	1	04	01	H0084_001_0	4	8	Group 8	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H0084	001	0	1	04	01	H0084_001_0	4	10	Group 10	01	0000000000000001111100000000000000000		2		1	13.00	15.00	2		1	2	1		20		20	1	25.00	50.00
H0084	004	0	1	04	01	H0084_004_0	4	11	Group 11	11	0000000000010000000000010000011100010	000001110000000010010000	2		1	0.00	0.00	2		2		2							
H0084	004	0	1	04	01	H0084_004_0	4	10	Group 10	10		000000000000000000000100	1	100.00	1	0.00	0.00	2		2		2							
H0084	004	0	1	04	01	H0084_004_0	4	1	Group 1	01	0111000001000000000000000000000001001		2		1	50.00	50.00	2		2		2							
H0084	004	0	1	04	01	H0084_004_0	4	12	Group 12	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H0084	004	0	1	04	01	H0084_004_0	4	9	Group 9	01	0000000000000001111100000000000000000		2		1	13.00	15.00	2		1	2	1		20		20	1	20.00	50.00
H0084	004	0	1	04	01	H0084_004_0	4	8	Group 8	01	0000000000000000000011000011100010000		2		2			2		2		1		20		20			
H0084	004	0	1	04	01	H0084_004_0	4	7	Group 7	01	0000000000000000000000000000000000100		2		1	0.00	50.00	2		2		2							
H0084	004	0	1	04	01	H0084_004_0	4	6	Group 6	01	0000000010100110000000100000000000000		2		1	30.00	40.00	2		2		2							
H0084	004	0	1	04	01	H0084_004_0	4	5	Group 5	11	0000001100000000000000000000000000000	000000000000000000100010	2		1	20.00	20.00	2		2		2							
H0084	004	0	1	04	01	H0084_004_0	4	4	Group 4	10		000000000000000000001000	2		1	25.00	25.00	2		2		2							
H0084	004	0	1	04	01	H0084_004_0	4	3	Group 3	01	0000000000000000000000000100000000000		2		2			2		2		1		50		50			
H0084	004	0	1	04	01	H0084_004_0	4	13	Group 13	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H0084	004	0	1	04	01	H0084_004_0	4	14	Group 14	01	0000000000001000000000000000000000000		2		1	20.00	50.00	2		2		2							
H0084	004	0	1	04	01	H0084_004_0	4	15	Group 15	01	0000010000000000000000000000000000000		2		2			2		2		1		40		40			
H0084	004	0	1	04	01	H0084_004_0	4	2	Group 2	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
H0084	014	0	1	04	01	H0084_014_0	3	3	Group 3	01	0000000000000000000000000000000000100		2		2			2		2		1		0		20			
H0084	014	0	1	04	01	H0084_014_0	3	2	Group 2	11	0000010000000000000000000000011100000	000001010000000010111010	2		1	0.00	0.00	2		2		2							
H0084	014	0	1	04	01	H0084_014_0	3	1	Group 1	01	0111101111111110000011111110100011011		2		2			2		2		1		20		20			
H0084	014	0	1	04	01	H0084_014_0	3	7	Group 7	10		000000000100000000000000	1	45.00	1	0.00	0.00	2		2		2							
H0084	014	0	1	04	01	H0084_014_0	3	6	Group 6	10		000000000000000000000100	1	125.00	1	0.00	0.00	2		2		2							
H0084	014	0	1	04	01	H0084_014_0	3	5	Group 5	01	0000000000000001111100000000000000000		2		2			2		1	1	1	20	20	20	20	2		
H0084	014	0	1	04	01	H0084_014_0	3	4	Group 4	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H0084	014	0	1	04	01	H0084_014_0	3	8	Group 8	01	0000000000000000000000000001000000000		2		2			2		2		1		20		30			
H0104	010	1	1	04	01	H0104_010_1	4	2	Ambulance Services	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H0104	010	1	1	04	01	H0104_010_1	4	3		01	0000000000000001111100000000000100000		2		2			2		1	1	1	30	30	30	30	2		
H0104	010	1	1	04	01	H0104_010_1	4	1		11	0111111111111110000011110111111011111	000000100000000010001000	2		2			2		2		1		30		30			
H0104	010	2	1	04	01	H0104_010_2	4	1		11	0111111111111110000011110111111011111	000000100000000010001000	2		2			2		2		1		30		30			
H0104	010	2	1	04	01	H0104_010_2	4	2	Ambulance Services	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H0104	010	2	1	04	01	H0104_010_2	4	3		01	0000000000000001111100000000000100000		2		2			2		1	1	1	30	30	30	30	2		
H0104	010	3	1	04	01	H0104_010_3	4	1		11	0111111111111110000011110111111011111	000000100000000010001000	2		2			2		2		1		30		30			
H0104	010	3	1	04	01	H0104_010_3	4	3		01	0000000000000001111100000000000100000		2		2			2		1	1	1	30	30	30	30	2		
H0104	010	3	1	04	01	H0104_010_3	4	2	Ambulance Services	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H0104	010	4	1	04	01	H0104_010_4	4	3		01	0000000000000001111100000000000100000		2		2			2		1	1	1	30	30	30	30	2		
H0104	010	4	1	04	01	H0104_010_4	4	2	Ambulance Services	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H0104	010	4	1	04	01	H0104_010_4	4	1		11	0111111111111110000011110111111011111	000000100000000010001000	2		2			2		2		1		30		30			
H0104	010	5	1	04	01	H0104_010_5	4	3		01	0000000000000001111100000000000100000		2		2			2		1	1	1	30	30	30	30	2		
H0104	010	5	1	04	01	H0104_010_5	4	1		11	0111111111111110000011110111111011111	000000100000000010001000	2		2			2		2		1		30		30			
H0104	010	5	1	04	01	H0104_010_5	4	2	Ambulance Services	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H0104	011	1	1	04	01	H0104_011_1	10	3		01	0000000000000001111100000000000100000		2		2			2		1	1	1	30	30	30	30	2		
H0104	011	1	1	04	01	H0104_011_1	10	2		01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H0104	011	1	1	04	01	H0104_011_1	10	1		11	0111111111111110000011110111111011111	000000100000000010001000	2		2			2		2		1		30		30			
H0104	011	2	1	04	01	H0104_011_2	8	3		01	0000000000000001111100000000000100000		2		2			2		1	1	1	30	30	30	30	2		
H0104	011	2	1	04	01	H0104_011_2	8	1		11	0111111111111110000011110111111011111	000000100000000010001000	2		2			2		2		1		30		30			
H0104	011	2	1	04	01	H0104_011_2	8	2		01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H0104	011	3	1	04	01	H0104_011_3	8	3		01	0000000000000001111100000000000100000		2		2			2		1	1	1	30	30	30	30	2		
H0104	011	3	1	04	01	H0104_011_3	8	2		01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H0104	011	3	1	04	01	H0104_011_3	8	1		11	0111111111111110000011110111111011111	000000100000000010001000	2		2			2		2		1		30		30			
H0104	011	4	1	04	01	H0104_011_4	8	3		01	0000000000000001111100000000000100000		2		2			2		1	1	1	30	30	30	30	2		
H0104	011	4	1	04	01	H0104_011_4	8	1		11	0111111111111110000011110111111011111	000000100000000010001000	2		2			2		2		1		30		30			
H0104	011	4	1	04	01	H0104_011_4	8	2		01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H0104	011	5	1	04	01	H0104_011_5	8	1		11	0111111111111110000011110111111011111	000000100000000010001000	2		2			2		2		1		30		30			
H0104	011	5	1	04	01	H0104_011_5	8	2		01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H0104	011	5	1	04	01	H0104_011_5	8	3		01	0000000000000001111100000000000100000		2		2			2		1	1	1	30	30	30	30	2		
H0104	011	6	1	04	01	H0104_011_6	8	1		11	0111111111111110000011110111111011111	000000100000000010001000	2		2			2		2		1		30		30			
H0104	011	6	1	04	01	H0104_011_6	8	2		01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H0104	011	6	1	04	01	H0104_011_6	8	3		01	0000000000000001111100000000000100000		2		2			2		1	1	1	30	30	30	30	2		
H0104	801	0	1	04	01	H0104_801_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H0104	801	0	1	04	01	H0104_801_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H0104	802	0	1	04	01	H0104_802_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H0104	802	0	1	04	01	H0104_802_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H0104	804	0	1	04	01	H0104_804_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H0104	804	0	1	04	01	H0104_804_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H0107	001	0	1	04	01	H0107_001_0	8	5	$350 Copay	01	0000000000000000000011000000000000000		2		1	350.00	350.00	2		2		2							
H0107	001	0	1	04	01	H0107_001_0	8	6	$100 Copay	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H0107	001	0	1	04	01	H0107_001_0	8	7	$0	11	0000010000000000000000010000011000000	000000000000000010000000	2		1	0.00	0.00	2		2		2							
H0107	001	0	1	04	01	H0107_001_0	8	4	$40 Copay	01	0000001100000000000000000000000000000		2		1	40.00	40.00	2		2		2							
H0107	001	0	1	04	01	H0107_001_0	8	3	$60 Copay	01	0000100000100100000000100000000000000		2		1	60.00	60.00	2		2		2							
H0107	001	0	1	04	01	H0107_001_0	8	2	65 Copay	01	0000000001011010000000000000000001100		2		1	65.00	65.00	2		2		2							
H0107	001	0	1	04	01	H0107_001_0	8	11	$400 Allowance	10		000000000000000000000001	1	400.00	2			2		2		2							
H0107	001	0	1	04	01	H0107_001_0	8	10	$175 Allowance	10		000000000000000000000100	1	175.00	2			2		2		2							
H0107	001	0	1	04	01	H0107_001_0	8	1	20%	01	0111000010000001111100000111100110000		2		2			2		2		1		20		20			
H0107	001	0	1	04	01	H0107_001_0	8	8	40% Coinsurance	11	0000000000000000000000000000000000011	000000000000000000000010	2		2			2		2		1		40		40			
H0107	001	0	1	04	01	H0107_001_0	8	9	$40 Allowance	10		000000000000000000001000	1	40.00	2			2		2		2							
H0107	002	0	1	04	01	H0107_002_0	9	1	20% Coinsurance	01	0111000010000001111100000111100110010		2		2			2		2		1		20		20			
H0107	002	0	1	04	01	H0107_002_0	9	10	$175 Allowance	10		000000000000000000000100	1	175.00	2			2		2		2							
H0107	002	0	1	04	01	H0107_002_0	9	2	$65 Copay	01	0000000000000000000000000000000000100		2		1	65.00	65.00	2		2		2							
H0107	002	0	1	04	01	H0107_002_0	9	3	$45 Copay	11	0000100001111110000000100000000001001	000000000000000000000010	2		1	45.00	45.00	2		2		2							
H0107	002	0	1	04	01	H0107_002_0	9	4	$40 Allowance	10		000000000000000000001000	1	40.00	2			2		2		2							
H0107	002	0	1	04	01	H0107_002_0	9	5	$275 Copay	01	0000000000000000000011000000000000000		2		1	275.00	275.00	2		2		2							
H0107	002	0	1	04	01	H0107_002_0	9	6	$100 Copay	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H0107	002	0	1	04	01	H0107_002_0	9	9	$400 Limit	10		000000000000000000000001	1	400.00	2			2		2		2							
H0107	002	0	1	04	01	H0107_002_0	9	8	$35 Copay	01	0000001100000000000000000000000000000		2		1	35.00	35.00	2		2		2							
H0107	002	0	1	04	01	H0107_002_0	9	7	$0.00 Copay	11	0000010000000000000000010000011000000	000000000000000010000000	2		1	0.00	0.00	2		2		2							
H0107	801	0	1	04	01	H0107_801_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H0107	801	0	1	04	01	H0107_801_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H0107	802	0	1	04	01	H0107_802_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H0107	802	0	1	04	01	H0107_802_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H0294	002	0	1	04	01	H0294_002_0	4	3	Group 3	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
H0294	002	0	1	04	01	H0294_002_0	4	13	Group 13	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H0294	002	0	1	04	01	H0294_002_0	4	15	Group 15	01	0000000010000010000000000000000000000		2		1	40.00	40.00	2		2		2							
H0294	002	0	1	04	01	H0294_002_0	4	14	Group 14	01	0000000000001000000000000000000000000		2		1	20.00	50.00	2		2		2							
H0294	002	0	1	04	01	H0294_002_0	4	9	Group 9	01	0000000000000001111100000000000000000		2		1	13.00	15.00	2		1	2	1		20		20	1	20.00	50.00
H0294	002	0	1	04	01	H0294_002_0	4	8	Group 8	01	0000000000000000000011000011100010000		2		2			2		2		1		20		20			
H0294	002	0	1	04	01	H0294_002_0	4	7	Group 7	10		000000000000000000001000	2		1	25.00	25.00	2		2		2							
H0294	002	0	1	04	01	H0294_002_0	4	6	Group 6	01	0000000000100100000000100000000000000		2		1	30.00	40.00	2		2		2							
H0294	002	0	1	04	01	H0294_002_0	4	5	Group 5	01	0000000000000000000000000000000000100		2		1	0.00	50.00	2		2		2							
H0294	002	0	1	04	01	H0294_002_0	4	4	Group 4	11	0000001100000000000000000000000000000	000000000000000000100010	2		1	20.00	20.00	2		2		2							
H0294	002	0	1	04	01	H0294_002_0	4	1	Group 1	01	0111000001000000000000000000000001001		2		1	50.00	50.00	2		2		2							
H0294	002	0	1	04	01	H0294_002_0	4	10	Group 10	10		000000000000000000000100	1	100.00	1	0.00	0.00	2		2		2							
H0294	002	0	1	04	01	H0294_002_0	4	11	Group 11	11	0000000000010000000000010000011100010	000001110000000010010000	2		1	0.00	0.00	2		2		2							
H0294	002	0	1	04	01	H0294_002_0	4	12	Group 12	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H0294	002	0	1	04	01	H0294_002_0	4	2	Group 2	01	0000010000000000000000000100000000000		2		2			2		2		1		50		50			
H0294	004	0	1	04	01	H0294_004_0	3	9	Group 9	01	0000000000000001111100000000000000000		2		1	13.00	15.00	2		1	2	1		20		20	1	20.00	50.00
H0294	004	0	1	04	01	H0294_004_0	3	8	Group 8	01	0000000000000000000011000011100010000		2		2			2		2		1		20		20			
H0294	004	0	1	04	01	H0294_004_0	3	5	Group 5	01	0000000000000000000000000000000000100		2		1	0.00	50.00	2		2		2							
H0294	004	0	1	04	01	H0294_004_0	3	6	Group 6	01	0000000010100110000000100000000000000		2		1	30.00	40.00	2		2		2							
H0294	004	0	1	04	01	H0294_004_0	3	7	Group 7	10		000000000000000000001000	2		1	25.00	25.00	2		2		2							
H0294	004	0	1	04	01	H0294_004_0	3	4	Group 4	11	0000001100000000000000000000000000000	000000000000000000100010	2		1	20.00	20.00	2		2		2							
H0294	004	0	1	04	01	H0294_004_0	3	3	Group 3	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
H0294	004	0	1	04	01	H0294_004_0	3	2	Group 2	01	0000010000000000000000000000000000000		2		2			2		2		1		50		50			
H0294	004	0	1	04	01	H0294_004_0	3	15	Group 15	01	0000000000000000000000000100000000000		2		2			2		2		1		40		40			
H0294	004	0	1	04	01	H0294_004_0	3	14	Group 14	01	0000000000001000000000000000000000000		2		1	20.00	50.00	2		2		2							
H0294	004	0	1	04	01	H0294_004_0	3	1	Group 1	11	0111000001010000000000000000000001001	000001000000000000000000	2		1	50.00	50.00	2		2		2							
H0294	004	0	1	04	01	H0294_004_0	3	10	Group 10	10		000000000000000000000100	1	100.00	1	0.00	0.00	2		2		2							
H0294	004	0	1	04	01	H0294_004_0	3	11	Group 11	11	0000000000000000000000010000011100010	000000100000000110010000	2		1	0.00	0.00	2		2		2							
H0294	004	0	1	04	01	H0294_004_0	3	12	Group 12	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H0294	004	0	1	04	01	H0294_004_0	3	13	Group 13	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H0294	006	0	1	04	01	H0294_006_0	3	1	Group 1	01	0111101111111110000011111110100011011		2		2			2		2		1		20		20			
H0294	006	0	1	04	01	H0294_006_0	3	2	Group 2	11	0000010000000000000000000000011100000	000000000000000010110000	2		1	0.00	0.00	2		2		2							
H0294	006	0	1	04	01	H0294_006_0	3	3	Group 3	01	0000000000000000000000000000000000100		2		2			2		2		1		0		20			
H0294	006	0	1	04	01	H0294_006_0	3	4	Group  4	01	0000000000000001111100000000000000000		2		2			2		1	1	1	20	20	20	20	2		
H0294	006	0	1	04	01	H0294_006_0	3	5	Group 5	10		000000000100000000000000	1	65.00	1	0.00	0.00	2		2		2							
H0294	006	0	1	04	01	H0294_006_0	3	6	Group 6	01	0000000000000000000000000001000000000		2		2			2		2		1		20		30			
H0319	001	0	1	04	01	H0319_001_0	4	1	Group 1	11	0111111111111110000011110111001111101	000001100000000000001010	2		2			2		2		1		30		30			
H0319	001	0	1	04	01	H0319_001_0	4	10	Group 10	10		000000000000000000000001	1	1400.00	1	0.00	0.00	2		2		2							
H0319	001	0	1	04	01	H0319_001_0	4	2	Group 2	11	0000000000000000000000000000000000010	000000000000000000010000	2		1	0.00	0.00	2		2		2							
H0319	001	0	1	04	01	H0319_001_0	4	3	Group 3	10		000000010000000000000000	2		2			2		2		1		75		75			
H0319	001	0	1	04	01	H0319_001_0	4	9	Group 9	10		000000000000000000000100	1	225.00	1	0.00	0.00	2		2		2							
H0319	001	0	1	04	01	H0319_001_0	4	5	Group 5	01	0000000000000000000000001000100000000		2		2			2		2		1		20		20			
H0319	001	0	1	04	01	H0319_001_0	4	6	Group 6	01	0000000000000001111100000000000000000		2		2			2		1	1	1	30	0	30	30	2		
H0319	001	0	1	04	01	H0319_001_0	4	7	Group 7	10		000000000100000000000000	1	85.00	1	0.00	0.00	2		2		2							
H0319	001	0	1	04	01	H0319_001_0	4	8	Group 8	10		000000000000000000100000	1	1800.00	1	0.00	0.00	2		2		2							
H0319	001	0	1	04	01	H0319_001_0	4	4	Group 4	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H0620	002	0	1	04	01	H0620_002_0	4	1	Group 1	11	0111111111111110000011110111001111101	000001100000000000001010	2		2			2		2		1		30		30			
H0620	002	0	1	04	01	H0620_002_0	4	2	Group 2	11	0000000000000000000000000000100000010	000000000000000000010001	2		1	0.00	0.00	2		2		2							
H0620	002	0	1	04	01	H0620_002_0	4	3	Group 3	10		000000010000000000000000	2		2			2		2		1		75		75			
H0620	002	0	1	04	01	H0620_002_0	4	4	Group 4	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H0620	002	0	1	04	01	H0620_002_0	4	9	Group 9	10		000000000000000000000100	1	200.00	1	0.00	0.00	2		2		2							
H0620	002	0	1	04	01	H0620_002_0	4	6	Group 6	01	0000000000000000000000001000000000000		2		1	75.00	75.00	2		2		2							
H0620	002	0	1	04	01	H0620_002_0	4	7	Group 7	10		000000000100000000000000	1	150.00	1	0.00	0.00	2		2		2							
H0620	002	0	1	04	01	H0620_002_0	4	8	Group 8	10		000000000000000000100000	1	1000.00	1	0.00	0.00	2		2		2							
H0620	002	0	1	04	01	H0620_002_0	4	5	Group 5	01	0000000000000001111100000000000000000		2		2			2		1	1	1	30	0	30	30	2		
H0710	001	0	1	04	01	H0710_001_0	5	1	Group 1	11	0111111111111110000011110111001111101	000001100000000000001000	2		2			2		2		1		30		30			
H0710	001	0	1	04	01	H0710_001_0	5	2	Group 2	01	0000000000000000000000000000000000010		2		1	0.00	0.00	2		2		2							
H0710	001	0	1	04	01	H0710_001_0	5	3	Group 3	01	0000000000000000000000001000100000000		2		2			2		2		1		20		20			
H0710	001	0	1	04	01	H0710_001_0	5	4	Group 4	10		000000010000000000000000	2		2			2		2		1		75		75			
H0710	001	0	1	04	01	H0710_001_0	5	9	Group 9	10		000000000000000000000100	1	150.00	1	0.00	0.00	2		2		2							
H0710	001	0	1	04	01	H0710_001_0	5	6	Group 6	01	0000000000000001111100000000000000000		2		2			2		1	1	1	30	0	30	30	2		
H0710	001	0	1	04	01	H0710_001_0	5	7	Group 7	10		000000000100000000000000	1	90.00	1	0.00	0.00	2		2		2							
H0710	001	0	1	04	01	H0710_001_0	5	8	Group 8	10		000000000000000000010000	1	250.00	1	0.00	0.00	2		2		2							
H0710	001	0	1	04	01	H0710_001_0	5	5	Group 5	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H0840	001	0	1	04	01	H0840_001_0	10	9	Chiropractic & OT Services	01	0000000110010010000000000000000000000		2		1	40.00	40.00	2		2		2							
H0840	001	0	1	04	01	H0840_001_0	10	1	Vision Hardware	10		000000000000000000000100	1	100.00	2			2		2		2							
H0840	001	0	1	04	01	H0840_001_0	10	10	Ambulance	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H0840	001	0	1	04	01	H0840_001_0	10	11	Kidney Disease Education	01	0000000000000000000000000000001000000		2		2			2		2		2							
H0840	001	0	1	04	01	H0840_001_0	10	12	ESRD	01	0000000000000000000000000000100000000		2		1	35.00	35.00	2		2		2							
H0840	001	0	1	04	01	H0840_001_0	10	13	Part Hosp & Part B Rx & Prosth & DM	01	0000100000000000000000000110000010000		2		2			2		2		1		30		30			
H0840	001	0	1	04	01	H0840_001_0	10	14	Preventive	11	0000000000000000000000000000010000000	000000000000000010000000	2		2			2		2		2							
H0840	001	0	1	04	01	H0840_001_0	10	15	Diabetes Education	01	0000000000000000000000000000000100000		2		1	40.00	40.00	2		2		2							
H0840	001	0	1	04	01	H0840_001_0	10	2	Radiology & Lab	01	0000000000000001111100000000000000000		2		2			2		1	2	1		20		20	1	60.00	60.00
H0840	001	0	1	04	01	H0840_001_0	10	3	Diabetic Supplies	01	0000000000000000000000000001000000000		2		1	0.00	0.00	2		2		2							
H0840	001	0	1	04	01	H0840_001_0	10	4	Outpatient Hospital Services	01	0111000000000000000010110000000000000		2		2			2		2		1		20		20			
H0840	001	0	1	04	01	H0840_001_0	10	5	Ambulatory Surgical Center	01	0000000000000000000001000000000000000		2		1	300.00	300.00	2		2		2							
H0840	001	0	1	04	01	H0840_001_0	10	6	Home Health Services	01	0000010000000000000000000000000000000		2		1	35.00	35.00	2		2		2							
H0840	001	0	1	04	01	H0840_001_0	10	7	Primary Care	01	0000001000000000000000000000000000000		2		1	50.00	50.00	2		2		2							
H0840	001	0	1	04	01	H0840_001_0	10	8	Specialist Services	11	0000000001101100000000000000000001111	000000000000000000001000	2		1	60.00	60.00	2		2		2							
H0840	002	0	1	04	01	H0840_002_0	11	1	Vision Hardware	10		000000000000000000000100	1	100.00	2			2		2		2							
H0840	002	0	1	04	01	H0840_002_0	11	10	Ambulance	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H0840	002	0	1	04	01	H0840_002_0	11	9	Chiropractic & Therapy	01	0000000110010010000000000000000000000		2		1	40.00	40.00	2		2		2							
H0840	002	0	1	04	01	H0840_002_0	11	8	Specialist Services	11	0000000001101100000000000000000001111	000000000000000000001000	2		1	60.00	60.00	2		2		2							
H0840	002	0	1	04	01	H0840_002_0	11	7	Primary Care	01	0000001000000000000000000000000000000		2		1	50.00	50.00	2		2		2							
H0840	002	0	1	04	01	H0840_002_0	11	6	Home Health Services	01	0000010000000000000000000000000000000		2		1	35.00	35.00	2		2		2							
H0840	002	0	1	04	01	H0840_002_0	11	5	Ambulatory Surgery Center	01	0000000000000000000001000000000000000		2		1	300.00	300.00	2		2		2							
H0840	002	0	1	04	01	H0840_002_0	11	4	Outpatient Hospital Services	01	0111000000000000000010110000000000000		2		2			2		2		1		20		20			
H0840	002	0	1	04	01	H0840_002_0	11	3	Diabetic Supplies	01	0000000000000000000000000001000000000		2		2			2		2		2							
H0840	002	0	1	04	01	H0840_002_0	11	2	Lab & Radiology	01	0000000000000001111100000000000000000		2		2			2		1	2	1		20		20	1	60.00	60.00
H0840	002	0	1	04	01	H0840_002_0	11	15	Diabetic Education	01	0000000000000000000000000000000100000		2		1	40.00	40.00	2		2		2							
H0840	002	0	1	04	01	H0840_002_0	11	14	Preventive	11	0000000000000000000000000000010000000	000000000000000010000000	2		2			2		2		2							
H0840	002	0	1	04	01	H0840_002_0	11	13	DME & Part Hosp & Part B & Prothetics	01	0000100000000000000000000110000010000		2		2			2		2		1		30		30			
H0840	002	0	1	04	01	H0840_002_0	11	12	ESRD	01	0000000000000000000000000000100000000		2		1	35.00	35.00	2		2		2							
H0840	002	0	1	04	01	H0840_002_0	11	11	ESRD Education	01	0000000000000000000000000000001000000		2		2			2		2		2							
H0879	001	0	1	04	01	H0879_001_0	9	8	OON Dental	10		000000000000000000100100	1	100.00	2			2		2		2							
H0879	001	0	1	04	01	H0879_001_0	9	7	OP Blood	11	0000000000000000000000010000000000000	000000100000000000000000	2		2			2		2		1		30		30			
H0879	001	0	1	04	01	H0879_001_0	9	6	Part B Drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		30		30			
H0879	001	0	1	04	01	H0879_001_0	9	5	Diabetes/Kidney Disease	01	0000000000000000000000000000001100000		2		2			2		2		2							
H0879	001	0	1	04	01	H0879_001_0	9	4	Ambulance	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H0879	001	0	1	04	01	H0879_001_0	9	3	Specialist/Healthcare Services	01	0000000001111100000000100000000000000		2		1	25.00	25.00	2		2		2							
H0879	001	0	1	04	01	H0879_001_0	9	9	OON Routine Eye Exam	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	35.00	35.00	2		2		2							
H0879	001	0	1	04	01	H0879_001_0	9	14	35 Copay	01	0000000000000000000000000000000000001		2		1	35.00	35.00	2		2		2							
H0879	001	0	1	04	01	H0879_001_0	9	13	Other	10		000000010000000000000000	2		2			2		2		2							
H0879	001	0	1	04	01	H0879_001_0	9	12	Other	11	0000000000000000000000000000010001010	000000000010000010000000	2		2			2		2		2							
H0879	001	0	1	04	01	H0879_001_0	9	11	Professional Service	01	0000000000000001111100000000000000000		2		2			2		1	2	1		30		30	1	25.00	30.00
H0879	001	0	1	04	01	H0879_001_0	9	10	Diabetic Supplies	01	0000000000000000000000000001000000000		2		2			2		2		1		20		20			
H0879	001	0	1	04	01	H0879_001_0	9	1	30% Co-Insurance	01	0111110110000010000011000110100000000		2		2			2		2		1		30		30			
H0879	001	0	1	04	01	H0879_001_0	9	2	PCP	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H0879	002	0	1	04	01	H0879_002_0	11	1	30% Cost Share	01	0111110110000010000011000110100000000		2		2			2		2		1		50		50			
H0879	002	0	1	04	01	H0879_002_0	11	10	OON Routine Eye Exam	10		000000000000000000001000	2		1	35.00	35.00	2		2		2							
H0879	002	0	1	04	01	H0879_002_0	11	9	OON Dental	10		000000000000000000100100	1	100.00	2			2		2		2							
H0879	002	0	1	04	01	H0879_002_0	11	8	Other	01	0000000000000000000000000000010001010		2		2			2		2		1		0		0			
H0879	002	0	1	04	01	H0879_002_0	11	7	OP Blood	11	0000000000000000000000010000000000000	000000100000000000000000	2		2			2		2		1		30		30			
H0879	002	0	1	04	01	H0879_002_0	11	6	Part B Drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		30		30			
H0879	002	0	1	04	01	H0879_002_0	11	5	Diabetes/Kidney Disease	01	0000000000000000000000000000001100000		2		2			2		2		2							
H0879	002	0	1	04	01	H0879_002_0	11	4	Ambulance	01	0000000000000000000000001000000000000		2		1	275.00	275.00	2		2		2							
H0879	002	0	1	04	01	H0879_002_0	11	3	Specialist/Healthcare Services	01	0000000001111100000000100000000000101		2		1	35.00	35.00	2		2		2							
H0879	002	0	1	04	01	H0879_002_0	11	2	PCP	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H0879	002	0	1	04	01	H0879_002_0	11	13	Other	10		000000010010000010000000	2		2			2		2		2							
H0879	002	0	1	04	01	H0879_002_0	11	12	Professional Services	01	0000000000000001111100000000000000000		2		2			2		1	2	1		50		50	1	30.00	35.00
H0879	002	0	1	04	01	H0879_002_0	11	11	Diabetic Supplies	01	0000000000000000000000000001000000000		2		2			2		2		1		20		20			
H0879	004	0	1	04	01	H0879_004_0	8	1	50% Cost Share	01	0111110110000010000011000110100000000		2		2			2		2		1		50		50			
H0879	004	0	1	04	01	H0879_004_0	8	10	OON Routine Eye Exam	10		000000000000000000001000	2		1	35.00	35.00	2		2		2							
H0879	004	0	1	04	01	H0879_004_0	8	4	Ambulance	01	0000000000000000000000001000000000000		2		1	275.00	275.00	2		2		2							
H0879	004	0	1	04	01	H0879_004_0	8	5	Diabetes/Kidney Disease	01	0000000000000000000000000000001100000		2		2			2		2		2							
H0879	004	0	1	04	01	H0879_004_0	8	6	Part B Drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		30		30			
H0879	004	0	1	04	01	H0879_004_0	8	7	OP Blood	11	0000000000000000000000010000000000000	000000100000000000000000	2		2			2		2		1		30		30			
H0879	004	0	1	04	01	H0879_004_0	8	8	Other	10		000000000000000000000100	1	100.00	2			2		2		2							
H0879	004	0	1	04	01	H0879_004_0	8	11	Diabetic Supplies	01	0000000000000000000000000001000000000		2		2			2		2		1		20		20			
H0879	004	0	1	04	01	H0879_004_0	8	12	Other	11	0000000000000000000000000000010001010	000000010010000010000000	2		2			2		2		2							
H0879	004	0	1	04	01	H0879_004_0	8	13	Group 14	01	0000000000000001111100000000000000000		2		2			2		1	2	1		50		50	1	35.00	35.00
H0879	004	0	1	04	01	H0879_004_0	8	2	PCP	01	0000001000000000000000000000000000000		2		1	35.00	35.00	2		2		2							
H0879	004	0	1	04	01	H0879_004_0	8	3	Specialist/Healthcare Services	01	0000000001111100000000100000000000101		2		1	35.00	35.00	2		2		2							
H0879	004	0	1	04	01	H0879_004_0	8	9	OON Dental	10		000000000000000000100000	1	100.00	2			2		2		2							
H0879	801	0	1	04	01	H0879_801_0	2	1	1	01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H0879	801	0	1	04	01	H0879_801_0	2	2	2	01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H0879	802	0	1	04	01	H0879_802_0	2	1	1	01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H0879	802	0	1	04	01	H0879_802_0	2	2	2	01	0111111111111111111111111111101111111		2		2			2		2		1		20		20			
H0879	803	0	1	04	01	H0879_803_0	2	1	1	01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H0879	803	0	1	04	01	H0879_803_0	2	2	2	01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1108	001	0	1	04	01	H1108_001_0	5	9	Group 9	10		000000000000000000000001	1	1600.00	1	0.00	0.00	2		2		2							
H1108	001	0	1	04	01	H1108_001_0	5	8	Group 8	10		000000000000000000000100	1	225.00	1	0.00	0.00	2		2		2							
H1108	001	0	1	04	01	H1108_001_0	5	7	Group 7	10		000000000100000000000000	1	75.00	1	0.00	0.00	2		2		2							
H1108	001	0	1	04	01	H1108_001_0	5	6	Group 6	01	0000000000000001111100000000000000000		2		2			2		1	1	1	30	0	30	30	2		
H1108	001	0	1	04	01	H1108_001_0	5	1	Group 1	11	0111111111111110000011110111001111101	000001100000000000001010	2		2			2		2		1		30		30			
H1108	001	0	1	04	01	H1108_001_0	5	4	Group 4	10		000000010000000000000000	2		2			2		2		1		75		75			
H1108	001	0	1	04	01	H1108_001_0	5	3	Group 3	01	0000000000000000000000001000100000000		2		2			2		2		1		20		20			
H1108	001	0	1	04	01	H1108_001_0	5	2	Group 2	01	0000000000000000000000000000000000010		2		1	0.00	0.00	2		2		2							
H1108	001	0	1	04	01	H1108_001_0	5	5	Group 5	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H1108	002	0	1	04	01	H1108_002_0	3	8	Group 8	10		000000000000000000100000	1	1000.00	1	0.00	0.00	2		2		2							
H1108	002	0	1	04	01	H1108_002_0	3	7	Group 7	10		000000000100000000000000	1	65.00	1	0.00	0.00	2		2		2							
H1108	002	0	1	04	01	H1108_002_0	3	6	Group 6	01	0000000000000001111100000000000000000		2		2			2		1	1	1	30	0	30	30	2		
H1108	002	0	1	04	01	H1108_002_0	3	5	Group 5	11	0000000000000000000000000000000000010	000000000000000010010000	2		1	0.00	0.00	2		2		2							
H1108	002	0	1	04	01	H1108_002_0	3	4	Group 4	01	0000000000000000000000001000100000000		2		2			2		2		1		20		20			
H1108	002	0	1	04	01	H1108_002_0	3	3	Group 3	10		000000010000000000000000	2		2			2		2		1		75		75			
H1108	002	0	1	04	01	H1108_002_0	3	2	Group 2	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H1108	002	0	1	04	01	H1108_002_0	3	10	Group 10	01	0000000000000000000000000000000010000		2		2			2		2		1		25		25			
H1108	002	0	1	04	01	H1108_002_0	3	9	Group 9	10		000000000000000000000100	1	150.00	1	0.00	0.00	2		2		2							
H1108	002	0	1	04	01	H1108_002_0	3	1	Group 1	11	0111111111111110000011110111001101101	000001100000000000001000	2		2			2		2		1		30		30			
H1291	001	0	1	09	04	H1291_001_0	3	1		11	0000010000000000000000010000011100010	000000100000000100000000	2		1	0.00	0.00	2		2		2							
H1291	001	0	1	09	04	H1291_001_0	3	9		01	0000000010100110000000000000000000000		2		1	40.00	40.00	2		2		2							
H1291	001	0	1	09	04	H1291_001_0	3	11		01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
H1291	001	0	1	09	04	H1291_001_0	3	12		01	0000000000000000001000000111100010000		2		2			2		2		1		20		20			
H1291	001	0	1	09	04	H1291_001_0	3	13		01	0000000000000000000010000000000000000		2		1	40.00	273.00	2		2		1		20		20			
H1291	001	0	1	09	04	H1291_001_0	3	14		10		000000000010000010110000	2		2			2		2		1		50		50			
H1291	001	0	1	09	04	H1291_001_0	3	15		10		000000000100000000000000	1	50.00	2			2		2		1		50		50			
H1291	001	0	1	09	04	H1291_001_0	3	2		10		000000000000000000001000	1	130.00	1	0.00	0.00	2		2		2							
H1291	001	0	1	09	04	H1291_001_0	3	3		01	0000000000000001100000000000000000100		2		1	0.00	50.00	2		2		2							
H1291	001	0	1	09	04	H1291_001_0	3	4		01	0000001100000000000000000000000000000		2		1	15.00	15.00	2		2		2							
H1291	001	0	1	09	04	H1291_001_0	3	5		01	0000000000000000010000000000000000000		2		1	15.00	273.00	2		2		2							
H1291	001	0	1	09	04	H1291_001_0	3	6		01	0000000000000000000100000000000000000		2		1	15.00	50.00	2		2		2							
H1291	001	0	1	09	04	H1291_001_0	3	7		01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H1291	001	0	1	09	04	H1291_001_0	3	8		01	0000000000000000000001000000000000000		2		1	223.00	223.00	2		2		2							
H1291	001	0	1	09	04	H1291_001_0	3	10		01	0111000001011000000000100000000001001		2		1	50.00	50.00	2		2		2							
H1302	001	0	1	04	01	H1302_001_0	6	1	No Cost Share	01	0000000000000000000000000000011100010		2		2			2		2		2							
H1302	001	0	1	04	01	H1302_001_0	6	2	$40 Copay	11	0111001111011010000000000000000000101	000000000000000000001000	2		1	40.00	40.00	2		2		2							
H1302	001	0	1	04	01	H1302_001_0	6	3	30% Coinsurance	11	0000110000100101111111110111100011000	000000100000000000000000	2		2			2		2		1		30		30			
H1302	001	0	1	04	01	H1302_001_0	6	4	$0 to $10 Copayment	10		000000000000000010000000	2		1	0.00	10.00	2		2		2							
H1302	001	0	1	04	01	H1302_001_0	6	5	$100 Vision Hardware Maximum	10		000000000000000000000100	1	100.00	2			2		2		2							
H1302	001	0	1	04	01	H1302_001_0	6	6	Ambulance $175 Copayment	01	0000000000000000000000001000000000000		2		1	175.00	175.00	2		2		2							
H1302	004	0	1	04	01	H1302_004_0	3	5	20% Coinsurance	01	0000010000000000000011000111100000000		2		2			2		2		1		20		20			
H1302	004	0	1	04	01	H1302_004_0	3	6	25% Coinsurance	11	0000100000100101111100110000000001000	000000100000000000000000	2		2			2		2		1		25		25			
H1302	004	0	1	04	01	H1302_004_0	3	7	$100 Vision Eyewear Maximum	10		000000000000000000000100	1	100.00	2			2		2		2							
H1302	004	0	1	04	01	H1302_004_0	3	8	$0 to $10 Copayment	10		000000000000000010000000	2		1	0.00	10.00	2		2		2							
H1302	004	0	1	04	01	H1302_004_0	3	4	30% Coinsurance	01	0000000000000000000000000000000010000		2		2			2		2		1		30		30			
H1302	004	0	1	04	01	H1302_004_0	3	3	Ambulance $175 Copayment	01	0000000000000000000000001000000000000		2		1	175.00	175.00	2		2		2							
H1302	004	0	1	04	01	H1302_004_0	3	2	$30 Copay	11	0111001111011010000000000000000000101	000000000000000000001000	2		1	30.00	30.00	2		2		2							
H1302	004	0	1	04	01	H1302_004_0	3	1	No Cost Share	01	0000000000000000000000000000011100010		2		2			2		2		2							
H1302	006	0	1	04	01	H1302_006_0	6	4	30% Coinsurance	11	0000110000100101111111110111100011000	000000100000000000000000	2		2			2		2		1		30		30			
H1302	006	0	1	04	01	H1302_006_0	6	3	Ambulance $175 Copayment	01	0000000000000000000000001000000000000		2		1	175.00	175.00	2		2		2							
H1302	006	0	1	04	01	H1302_006_0	6	6	$0 to $10 Coapyment	10		000000000000000010000000	2		1	0.00	10.00	2		2		2							
H1302	006	0	1	04	01	H1302_006_0	6	5	$100 Vision Eyewear Maximum	10		000000000000000000000100	1	100.00	2			2		2		2							
H1302	006	0	1	04	01	H1302_006_0	6	2	$40 Copay	11	0111001111011010000000000000000000101	000000000000000000001000	2		1	40.00	40.00	2		2		2							
H1302	006	0	1	04	01	H1302_006_0	6	1	No Cost Share	01	0000000000000000000000000000011100010		2		2			2		2		2							
H1303	001	0	1	04	01	H1303_001_0	4	4	Group 4	01	0000000000000001111100000000000000000		2		1	13.00	21.00	2		1	2	1		30		30	1	35.00	65.00
H1303	001	0	1	04	01	H1303_001_0	4	5	Group 5	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H1303	001	0	1	04	01	H1303_001_0	4	6	Group 6	01	0000100000000000000000000000000000000		2		1	75.00	75.00	2		2		2							
H1303	001	0	1	04	01	H1303_001_0	4	12	Group 12	01	0000010000000000000000000100000000000		2		2			2		2		1		50		50			
H1303	001	0	1	04	01	H1303_001_0	4	11	Group 11	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H1303	001	0	1	04	01	H1303_001_0	4	10	Group 10	11	0000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H1303	001	0	1	04	01	H1303_001_0	4	13	Group 13	01	0000000000001000000000000000000000000		2		1	35.00	65.00	2		2		2							
H1303	001	0	1	04	01	H1303_001_0	4	7	Group 7	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H1303	001	0	1	04	01	H1303_001_0	4	8	Group 8	01	0000000000100100000000100000000000000		2		1	35.00	45.00	2		2		2							
H1303	001	0	1	04	01	H1303_001_0	4	9	Group 9	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H1303	001	0	1	04	01	H1303_001_0	4	3	Group 3	11	0000000000000000000011000011001110010	000000000000000100000000	2		2			2		2		1		30		30			
H1303	001	0	1	04	01	H1303_001_0	4	2	Group 2	11	0111000111010010000000000000000001101	000001000000000000001010	2		1	65.00	65.00	2		2		2							
H1303	001	0	1	04	01	H1303_001_0	4	1	Group 1	01	0000001000000000000000000000000000000		2		1	35.00	35.00	2		2		2							
H1303	007	0	1	04	01	H1303_007_0	4	11	Group 11	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H1303	007	0	1	04	01	H1303_007_0	4	10	Group 10	11	0000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H1303	007	0	1	04	01	H1303_007_0	4	1	Group 1	01	0000001000000000000000000000000000000		2		1	25.00	25.00	2		2		2							
H1303	007	0	1	04	01	H1303_007_0	4	9	Group 9	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H1303	007	0	1	04	01	H1303_007_0	4	8	Group 8	01	0000000000100100000000100000000000000		2		1	35.00	45.00	2		2		2							
H1303	007	0	1	04	01	H1303_007_0	4	7	Group 7	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H1303	007	0	1	04	01	H1303_007_0	4	6	Group 6	01	0000100000000000000000000000000000000		2		1	75.00	75.00	2		2		2							
H1303	007	0	1	04	01	H1303_007_0	4	5	Group 5	10		000000000000000000100000	2		1	40.00	40.00	2		2		2							
H1303	007	0	1	04	01	H1303_007_0	4	4	Group 4	01	0000000000000001111100000000000000000		2		1	13.00	21.00	2		1	2	1		30		30	1	25.00	60.00
H1303	007	0	1	04	01	H1303_007_0	4	3	Group 3	11	0000000000000000000011000011001110010	000000000000000100000000	2		2			2		2		1		30		30			
H1303	007	0	1	04	01	H1303_007_0	4	2	Group 2	11	0111000111010010000000000000000001101	000001000000000000001010	2		1	60.00	60.00	2		2		2							
H1303	007	0	1	04	01	H1303_007_0	4	14	Group 14	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H1303	007	0	1	04	01	H1303_007_0	4	12	Group 12	01	0000010000000000000000000100000000000		2		2			2		2		1		50		50			
H1303	007	0	1	04	01	H1303_007_0	4	13	Group 13	01	0000000000001000000000000000000000000		2		1	25.00	60.00	2		2		2							
H1304	001	0	1	04	01	H1304_001_0	8	1	$25 copay	01	0000001100010000000000000000000000000		2		1	25.00	25.00	2		2		2							
H1304	001	0	1	04	01	H1304_001_0	8	10	10% coinsurance	01	0000000000000000000000000000100000000		2		2			2		2		1		10		10			
H1304	001	0	1	04	01	H1304_001_0	8	11	20% coinsurance	01	0000010000000000000000000000000010000		2		2			2		2		1		20		20			
H1304	001	0	1	04	01	H1304_001_0	8	12	30% coinsurance	01	0000000000000000011100000110000000000		2		2			2		2		1		30		30			
H1304	001	0	1	04	01	H1304_001_0	8	2	$50 copay	01	0111000011101110000000100000000001101		2		1	50.00	50.00	2		2		2							
H1304	001	0	1	04	01	H1304_001_0	8	3	Dental Preventive Services $500 maximum	10		000000000000000000100000	1	500.00	2			2		2		1		50		50			
H1304	001	0	1	04	01	H1304_001_0	8	4	0 - Zero cost share	11	0000100000000001100000010001011100010	000000100000000110000000	2		2			2		2		2							
H1304	001	0	1	04	01	H1304_001_0	8	5	$0 to $225 copay	01	0000000000000000000010000000000000000		2		1	0.00	225.00	2		2		2							
H1304	001	0	1	04	01	H1304_001_0	8	6	$0 to $150 copay	01	0000000000000000000001000000000000000		2		1	0.00	150.00	2		2		2							
H1304	001	0	1	04	01	H1304_001_0	8	7	$35 copay VSP exam	10		000000000000000000001000	2		1	35.00	35.00	2		2		2							
H1304	001	0	1	04	01	H1304_001_0	8	8	VSP Eyewear $100 Maximum	10		000000000000000000000100	1	100.00	2			2		2		2							
H1304	001	0	1	04	01	H1304_001_0	8	9	$200 copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H1304	002	0	1	04	01	H1304_002_0	9	9	$200 copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H1304	002	0	1	04	01	H1304_002_0	9	8	VSP Eyewear $100 Maximum	10		000000000000000000000100	1	100.00	2			2		2		2							
H1304	002	0	1	04	01	H1304_002_0	9	7	$35 copay VSP exam	10		000000000000000000001000	2		1	35.00	35.00	2		2		2							
H1304	002	0	1	04	01	H1304_002_0	9	6	$0 to $150 copay	01	0000000000000000000001000000000000000		2		1	0.00	150.00	2		2		2							
H1304	002	0	1	04	01	H1304_002_0	9	5	$0 to $225 copay	01	0000000000000000000010000000000000000		2		1	0.00	225.00	2		2		2							
H1304	002	0	1	04	01	H1304_002_0	9	2	$50 copay	01	0111000011101110000000100000000001101		2		1	50.00	50.00	2		2		2							
H1304	002	0	1	04	01	H1304_002_0	9	3	Dental Preventive Services $500 maximum	10		000000000000000000100000	1	500.00	2			2		2		1		50		50			
H1304	002	0	1	04	01	H1304_002_0	9	1	$25 copay	01	0000001100010000000000000000000000000		2		1	25.00	25.00	2		2		2							
H1304	002	0	1	04	01	H1304_002_0	9	10	10% coinsurance	01	0000000000000000000000000000100000000		2		2			2		2		1		10		10			
H1304	002	0	1	04	01	H1304_002_0	9	11	20% coinsurance	11	0000010000000000000000000000000010000	000000000000000001000000	2		2			2		2		1		20		20			
H1304	002	0	1	04	01	H1304_002_0	9	12	30% coinsurance	01	0000000000000000011100000110000000000		2		2			2		2		1		30		30			
H1304	002	0	1	04	01	H1304_002_0	9	4	0 - Zero cost share	11	0000100000000001100000010001011100010	000000100000000110000000	2		2			2		2		2							
H1304	004	0	1	04	01	H1304_004_0	9	8	VSP Eyewear $200 Maximum	10		000000000000000000000100	1	200.00	2			2		2		2							
H1304	004	0	1	04	01	H1304_004_0	9	7	$25 copay VSP exam	10		000000000000000000001000	2		1	25.00	25.00	2		2		2							
H1304	004	0	1	04	01	H1304_004_0	9	6	$0 to $150 copay	01	0000000000000000000001000000000000000		2		1	0.00	150.00	2		2		2							
H1304	004	0	1	04	01	H1304_004_0	9	5	$0 to $175 copay	01	0000000000000000000010000000000000000		2		1	0.00	175.00	2		2		2							
H1304	004	0	1	04	01	H1304_004_0	9	4	0 - Zero cost share	11	0000100000000001100000010001011100010	000000100000000110000000	2		2			2		2		2							
H1304	004	0	1	04	01	H1304_004_0	9	3	Dental Preventive Services $500 maximum	10		000000000000000000100000	1	500.00	2			2		2		1		50		50			
H1304	004	0	1	04	01	H1304_004_0	9	2	$40 copay	01	0111000011101110000000100000000001101		2		1	40.00	40.00	2		2		2							
H1304	004	0	1	04	01	H1304_004_0	9	13	30% coinsurance	01	0000000000000000011100000000000000000		2		2			2		2		1		30		30			
H1304	004	0	1	04	01	H1304_004_0	9	12	Hearing Aid - $500 maximum	10		000000000000000000000001	1	500.00	2			2		2		2							
H1304	004	0	1	04	01	H1304_004_0	9	11	20% coinsurance	01	0000000000000000000000000110000000000		2		2			2		2		1		20		20			
H1304	004	0	1	04	01	H1304_004_0	9	10	10% coinsurance	11	0000010000000000000000000000100010000	000000000000000001000000	2		2			2		2		1		10		10			
H1304	004	0	1	04	01	H1304_004_0	9	9	$200 copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H1304	004	0	1	04	01	H1304_004_0	9	1	$20 copay	01	0000001100010000000000000000000000000		2		1	20.00	20.00	2		2		2							
H1304	008	0	1	04	01	H1304_008_0	8	2	$50 copay	01	0111000011101110000000100000000001101		2		1	50.00	50.00	2		2		2							
H1304	008	0	1	04	01	H1304_008_0	8	12	30% coinsurance	01	0000000000000000011100000110000000000		2		2			2		2		1		30		30			
H1304	008	0	1	04	01	H1304_008_0	8	11	20% coinsurance	01	0000010000000000000000000000000010000		2		2			2		2		1		20		20			
H1304	008	0	1	04	01	H1304_008_0	8	10	10% coinsurance	01	0000000000000000000000000000100000000		2		2			2		2		1		10		10			
H1304	008	0	1	04	01	H1304_008_0	8	1	$25 copay	01	0000001100010000000000000000000000000		2		1	25.00	25.00	2		2		2							
H1304	008	0	1	04	01	H1304_008_0	8	3	Dental Preventive Services $500 maximum	10		000000000000000000100000	1	500.00	2			2		2		1		50		50			
H1304	008	0	1	04	01	H1304_008_0	8	9	$200 copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H1304	008	0	1	04	01	H1304_008_0	8	8	VSP Eyewear $100 Maximum	10		000000000000000000000100	1	100.00	2			2		2		2							
H1304	008	0	1	04	01	H1304_008_0	8	7	$35 copay VSP exam	10		000000000000000000001000	2		1	35.00	35.00	2		2		2							
H1304	008	0	1	04	01	H1304_008_0	8	6	$0 to $150 copay	01	0000000000000000000001000000000000000		2		1	0.00	150.00	2		2		2							
H1304	008	0	1	04	01	H1304_008_0	8	5	$0 to $225 copay	01	0000000000000000000010000000000000000		2		1	0.00	225.00	2		2		2							
H1304	008	0	1	04	01	H1304_008_0	8	4	0 - Zero cost share	11	0000100000000001100000010001011100010	000000100000000110000000	2		2			2		2		2							
H1304	009	0	1	04	01	H1304_009_0	9	9	$200 copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H1304	009	0	1	04	01	H1304_009_0	9	8	VSP Eyewear $100 Maximum	10		000000000000000000000100	1	100.00	2			2		2		2							
H1304	009	0	1	04	01	H1304_009_0	9	7	$35 copay VSP exam	10		000000000000000000001000	2		1	35.00	35.00	2		2		2							
H1304	009	0	1	04	01	H1304_009_0	9	6	$0 to $150 copay	01	0000000000000000000001000000000000000		2		1	0.00	150.00	2		2		2							
H1304	009	0	1	04	01	H1304_009_0	9	5	$0 to $225 copay	01	0000000000000000000010000000000000000		2		1	0.00	225.00	2		2		2							
H1304	009	0	1	04	01	H1304_009_0	9	1	$25 copay	01	0000001100010000000000000000000000000		2		1	25.00	25.00	2		2		2							
H1304	009	0	1	04	01	H1304_009_0	9	3	Dental Preventive Services $500 maximum	10		000000000000000000100000	1	500.00	2			2		2		1		50		50			
H1304	009	0	1	04	01	H1304_009_0	9	2	$50 copay	01	0111000011101110000000100000000001101		2		1	50.00	50.00	2		2		2							
H1304	009	0	1	04	01	H1304_009_0	9	12	30% coinsurance	01	0000000000000000011100000110000000000		2		2			2		2		1		30		30			
H1304	009	0	1	04	01	H1304_009_0	9	11	20% coinsurance	11	0000010000000000000000000000000010000	000000000000000001000000	2		2			2		2		1		20		20			
H1304	009	0	1	04	01	H1304_009_0	9	10	10% coinsurance	01	0000000000000000000000000000100000000		2		2			2		2		1		10		10			
H1304	009	0	1	04	01	H1304_009_0	9	4	0 - Zero cost share	11	0000100000000001100000010001011100010	000000100000000110000000	2		2			2		2		2							
H1304	010	0	1	04	01	H1304_010_0	9	3	Dental Preventive Services $500 maximum	10		000000000000000000100000	1	500.00	2			2		2		1		50		50			
H1304	010	0	1	04	01	H1304_010_0	9	4	0 - Zero cost share	11	0000100000000001100000010001011100010	000000100000000110000000	2		2			2		2		2							
H1304	010	0	1	04	01	H1304_010_0	9	5	$0 to $175 copay	01	0000000000000000000010000000000000000		2		1	0.00	175.00	2		2		2							
H1304	010	0	1	04	01	H1304_010_0	9	6	$0 to $150 copay	01	0000000000000000000001000000000000000		2		1	0.00	150.00	2		2		2							
H1304	010	0	1	04	01	H1304_010_0	9	7	$25 copay VSP exam	10		000000000000000000001000	2		1	25.00	25.00	2		2		2							
H1304	010	0	1	04	01	H1304_010_0	9	8	VSP Eyewear $200 Maximum	10		000000000000000000000100	1	200.00	2			2		2		2							
H1304	010	0	1	04	01	H1304_010_0	9	2	$40 copay	01	0111000011101110000000100000000001101		2		1	40.00	40.00	2		2		2							
H1304	010	0	1	04	01	H1304_010_0	9	13	30% coinsurance	01	0000000000000000011100000000000000000		2		2			2		2		1		30		30			
H1304	010	0	1	04	01	H1304_010_0	9	12	Hearing Aid - $500 maximum	10		000000000000000000000001	1	500.00	2			2		2		2							
H1304	010	0	1	04	01	H1304_010_0	9	11	20% coinsurance	01	0000000000000000000000000110000000000		2		2			2		2		1		20		20			
H1304	010	0	1	04	01	H1304_010_0	9	10	10% coinsurance	11	0000010000000000000000000000100010000	000000000000000001000000	2		2			2		2		1		10		10			
H1304	010	0	1	04	01	H1304_010_0	9	9	$200 copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H1304	010	0	1	04	01	H1304_010_0	9	1	$20 copay	01	0000001100010000000000000000000000000		2		1	20.00	20.00	2		2		2							
H1304	803	0	1	04	01	H1304_803_0	8	1	$0 copay	01	0000010000000000100000000000010000000		2		2			2		2		2							
H1304	803	0	1	04	01	H1304_803_0	8	2	20% coinsurance	01	0111101111111111011111111111101111111		2		2			2		2		1		20		20			
H1304	804	0	1	04	01	H1304_804_0	8	2	20% coinsurance	01	0111101111111111011111111111101111111		2		2			2		2		1		20		20			
H1304	804	0	1	04	01	H1304_804_0	8	1	$0 copay	01	0000010000000000100000000000010000000		2		2			2		2		2							
H1365	001	0	1	04	01	H1365_001_0	7	4	4	01	0000000000000000100000000000000000000		2		2			2		2		1		0		20			
H1365	001	0	1	04	01	H1365_001_0	7	3	3	01	0000000000000001000000000000000000000		2		1	0.00	75.00	2		2		2							
H1365	001	0	1	04	01	H1365_001_0	7	2	2	01	0000010000000000000000000001100010000		2		2			2		2		1		20		20			
H1365	001	0	1	04	01	H1365_001_0	7	1	1	11	0111100111111110011011110110010001111	000000000000000100001000	2		2			2		2		1		30		30			
H1365	001	0	1	04	01	H1365_001_0	7	5	5	11	0000000000000000000000000000001100000	000000000000000010000000	2		2			2		2		2							
H1365	001	0	1	04	01	H1365_001_0	7	6	6	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H1365	001	0	1	04	01	H1365_001_0	7	7	7	01	0000001000000000000000000000000000000		2		1	25.00	25.00	2		2		2							
H1365	001	0	1	04	01	H1365_001_0	7	8	8	01	0000000000000000000100000000000000000		2		1	15.00	15.00	2		2		2							
H1365	002	0	1	04	01	H1365_002_0	7	4	4	01	0000000000000000100000000000000000000		2		2			2		2		1		0		20			
H1365	002	0	1	04	01	H1365_002_0	7	3	3	01	0000000000000001000000000000000000000		2		1	0.00	75.00	2		2		2							
H1365	002	0	1	04	01	H1365_002_0	7	2	2	01	0000010000000000000000000001100010000		2		2			2		2		1		20		20			
H1365	002	0	1	04	01	H1365_002_0	7	1	1	11	0111100111111110011011110110010001111	000000000000000100001000	2		2			2		2		1		30		30			
H1365	002	0	1	04	01	H1365_002_0	7	5	5	11	0000000000000000000000000000001100000	000000000000000010000000	2		2			2		2		2							
H1365	002	0	1	04	01	H1365_002_0	7	7	7	01	0000001000000000000100000000000000000		2		1	15.00	25.00	2		2		2							
H1365	002	0	1	04	01	H1365_002_0	7	6	6	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H1365	003	0	1	04	01	H1365_003_0	7	1	1	11	0111100111111110011011110110010001111	000000000000000100001000	2		2			2		2		1		30		30			
H1365	003	0	1	04	01	H1365_003_0	7	2	2	01	0000010000000000000000000001100010000		2		2			2		2		1		20		20			
H1365	003	0	1	04	01	H1365_003_0	7	3	3	01	0000000000000001000000000000000000000		2		1	0.00	75.00	2		2		2							
H1365	003	0	1	04	01	H1365_003_0	7	4	4	01	0000000000000000100000000000000000000		2		2			2		2		1		0		20			
H1365	003	0	1	04	01	H1365_003_0	7	5	5	11	0000000000000000000000000000001100000	000000000000000010000000	2		2			2		2		2							
H1365	003	0	1	04	01	H1365_003_0	7	6	6	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H1365	003	0	1	04	01	H1365_003_0	7	7	7	01	0000001000000000000100000000000000000		2		1	15.00	25.00	2		2		2							
H1365	802	0	1	04	01	H1365_802_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1365	802	0	1	04	01	H1365_802_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1365	803	0	1	04	01	H1365_803_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1365	803	0	1	04	01	H1365_803_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1417	001	0	1	04	01	H1417_001_0	2	3	Ambulance	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H1417	001	0	1	04	01	H1417_001_0	2	2	Renal Dialysis	11	0000000000000000000000010000100000000	000000100000000000000000	2		2			2		2		2							
H1417	001	0	1	04	01	H1417_001_0	2	1	Office Visits	11	0111111010000011111100000000011101101	000000000000000110001010	2		1	30.00	30.00	2		2		2							
H1417	001	0	1	04	01	H1417_001_0	2	4	DME	01	0000000000000000000000000111000000000		2		2			2		2		1		20		20			
H1417	001	0	1	04	01	H1417_001_0	2	9	Preventive Dental	10		000000000000000000100000	2		1	0.00	20.00	2		2		2							
H1417	001	0	1	04	01	H1417_001_0	2	6	Eye Wear	01	0000000000000000000000000000000000010		2		2			2		2		2							
H1417	001	0	1	04	01	H1417_001_0	2	7	Specialty Visits	01	0000000101111100000000100000000000000		2		1	40.00	40.00	2		2		2							
H1417	001	0	1	04	01	H1417_001_0	2	8	Part B Drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		20		20			
H1417	001	0	1	04	01	H1417_001_0	2	5	ASC	01	0000000000000000000011000000000000000		2		1	200.00	200.00	2		2		2							
H1417	002	0	1	04	01	H1417_002_0	3	3	Ambulance	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H1417	002	0	1	04	01	H1417_002_0	3	2	Renal Dialysis	11	0000000000000000000000010000100000000	000000100000000000000000	2		2			2		2		2							
H1417	002	0	1	04	01	H1417_002_0	3	1	Office Visits	11	0111111010000011111100000000011101101	000000000000000110001010	2		1	30.00	30.00	2		2		2							
H1417	002	0	1	04	01	H1417_002_0	3	4	DME	01	0000000000000000000000000111000000000		2		2			2		2		1		20		20			
H1417	002	0	1	04	01	H1417_002_0	3	9	Preventive Dental	10		000000000000000000100000	2		1	0.00	20.00	2		2		2							
H1417	002	0	1	04	01	H1417_002_0	3	8	Part B Drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		20		20			
H1417	002	0	1	04	01	H1417_002_0	3	7	Specialty Visits	01	0000000101111100000000100000000000000		2		1	40.00	40.00	2		2		2							
H1417	002	0	1	04	01	H1417_002_0	3	6	Eye Wear	01	0000000000000000000000000000000000010		2		2			2		2		2							
H1417	002	0	1	04	01	H1417_002_0	3	5	ASC	01	0000000000000000000011000000000000000		2		1	200.00	200.00	2		2		2							
H1417	003	0	1	04	01	H1417_003_0	2	1	Office Visits	11	0111111111111111111100100000011101101	000000000000000110001000	2		1	50.00	50.00	2		2		2							
H1417	003	0	1	04	01	H1417_003_0	2	2	Renal Dialysis	11	0000000000000000000000010000100000000	000000100000000000000000	2		2			2		2		2							
H1417	003	0	1	04	01	H1417_003_0	2	7	Part B Drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		20		20			
H1417	003	0	1	04	01	H1417_003_0	2	6	Eye Wear	01	0000000000000000000000000000000000010		2		2			2		2		2							
H1417	003	0	1	04	01	H1417_003_0	2	5	ASC	01	0000000000000000000011000000000000000		2		1	200.00	200.00	2		2		2							
H1417	003	0	1	04	01	H1417_003_0	2	4	DME	01	0000000000000000000000000111000000000		2		2			2		2		1		20		20			
H1417	003	0	1	04	01	H1417_003_0	2	3	Ambulance	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H1417	003	0	1	04	01	H1417_003_0	2	8	Preventive Dental	10		000000000000000000100000	2		1	0.00	20.00	2		2		2							
H1417	004	0	1	04	01	H1417_004_0	3	1	Office Visits	11	0111111111111111111100100000011101101	000000000000000110001000	2		1	50.00	50.00	2		2		2							
H1417	004	0	1	04	01	H1417_004_0	3	2	Renal Dialysis	11	0000000000000000000000010000100000000	000000100000000000000000	2		2			2		2		2							
H1417	004	0	1	04	01	H1417_004_0	3	8	Preventive Dental	10		000000000000000000100000	2		1	0.00	20.00	2		2		2							
H1417	004	0	1	04	01	H1417_004_0	3	7	Part B Drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		20		20			
H1417	004	0	1	04	01	H1417_004_0	3	6	Eye Wear	01	0000000000000000000000000000000000010		2		2			2		2		2							
H1417	004	0	1	04	01	H1417_004_0	3	5	ASC	01	0000000000000000000011000000000000000		2		1	200.00	200.00	2		2		2							
H1417	004	0	1	04	01	H1417_004_0	3	4	DME	01	0000000000000000000000000111000000000		2		2			2		2		1		20		20			
H1417	004	0	1	04	01	H1417_004_0	3	3	Ambulance	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H1417	010	0	1	04	01	H1417_010_0	3	1	Office Visits	11	0111011111111111111100100000011101101	000000000000000110001010	2		1	50.00	50.00	2		2		2							
H1417	010	0	1	04	01	H1417_010_0	3	2	Renal Dialysis	11	0000000000000000000000010000100000000	000000100000000000000000	2		2			2		2		2							
H1417	010	0	1	04	01	H1417_010_0	3	3	Ambulance	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H1417	010	0	1	04	01	H1417_010_0	3	4	DME	01	0000000000000000000000000111000000000		2		2			2		2		1		20		20			
H1417	010	0	1	04	01	H1417_010_0	3	9	Preventive Dental	10		000000000000000000100000	2		1	0.00	25.00	2		2		2							
H1417	010	0	1	04	01	H1417_010_0	3	6	Eye Wear	01	0000000000000000000000000000000000010		2		2			2		2		2							
H1417	010	0	1	04	01	H1417_010_0	3	7	Partial Hospitalization	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
H1417	010	0	1	04	01	H1417_010_0	3	8	Part B Drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		20		20			
H1417	010	0	1	04	01	H1417_010_0	3	5	ASC	01	0000000000000000000011000000000000000		2		2			2		2		1		20		20			
H1417	011	0	1	04	01	H1417_011_0	2	1	Office Visits	11	0111011111111111111100100000011101101	000000000000000110001010	2		1	50.00	50.00	2		2		2							
H1417	011	0	1	04	01	H1417_011_0	2	2	Renal Dialysis	11	0000000000000000000000010000100000000	000000100000000000000000	2		2			2		2		2							
H1417	011	0	1	04	01	H1417_011_0	2	7	Partial Hospitalization	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
H1417	011	0	1	04	01	H1417_011_0	2	8	Part B Drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		20		20			
H1417	011	0	1	04	01	H1417_011_0	2	9	Preventive Dental	10		000000000000000000100000	2		1	0.00	25.00	2		2		2							
H1417	011	0	1	04	01	H1417_011_0	2	3	Ambulance	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H1417	011	0	1	04	01	H1417_011_0	2	4	DME	01	0000000000000000000000000111000000000		2		2			2		2		1		20		20			
H1417	011	0	1	04	01	H1417_011_0	2	5	ASC	01	0000000000000000000011000000000000000		2		2			2		2		1		20		20			
H1417	011	0	1	04	01	H1417_011_0	2	6	Eye Wear	01	0000000000000000000000000000000000010		2		2			2		2		2							
H1417	801	0	1	04	01	H1417_801_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1417	801	0	1	04	01	H1417_801_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1417	802	0	1	04	01	H1417_802_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1417	802	0	1	04	01	H1417_802_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1417	810	0	1	04	01	H1417_810_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1417	810	0	1	04	01	H1417_810_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1418	002	0	1	04	01	H1418_002_0	4	3		10		000000000000000000001000	1	40.00	1	0.00	0.00	2		2		2							
H1418	002	0	1	04	01	H1418_002_0	4	2		10		000000000000000000000100	1	100.00	1	0.00	0.00	2		2		2							
H1418	002	0	1	04	01	H1418_002_0	4	1		11	0000000000000000000000010000000000010	000000100000000000000000	2		1	0.00	0.00	2		2		2							
H1418	002	0	1	04	01	H1418_002_0	4	4		01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H1418	002	0	1	04	01	H1418_002_0	4	9		10		000000000100000000000000	1	50.00	2			2		2		1		50		50			
H1418	002	0	1	04	01	H1418_002_0	4	6		01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H1418	002	0	1	04	01	H1418_002_0	4	7		01	0000000000000000000010000000000000000		2		2			2		2		1		20		50			
H1418	002	0	1	04	01	H1418_002_0	4	8		11	0111111111111111111101100111001111101	000000000010000110110000	2		2			2		2		1		50		50			
H1418	002	0	1	04	01	H1418_002_0	4	5		01	0000000000000000000000000000010000000		2		2			2		2		1		0		50			
H1418	007	0	1	04	01	H1418_007_0	4	3		01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H1418	007	0	1	04	01	H1418_007_0	4	2		10		000000000000000000001000	1	40.00	1	0.00	0.00	2		2		2							
H1418	007	0	1	04	01	H1418_007_0	4	1		11	0000000000000000000000010000000000010	000000100000000000000000	2		1	0.00	0.00	2		2		2							
H1418	007	0	1	04	01	H1418_007_0	4	4		10		000000000000000000000010	2		1	35.00	35.00	2		2		2							
H1418	007	0	1	04	01	H1418_007_0	4	9		10		000000000100000000000000	1	50.00	2			2		2		1		50		50			
H1418	007	0	1	04	01	H1418_007_0	4	8		11	0111111111111111111101100111001111101	000001000010000110110000	2		2			2		2		1		50		50			
H1418	007	0	1	04	01	H1418_007_0	4	7		01	0000000000000000000010000000000000000		2		2			2		2		1		20		50			
H1418	007	0	1	04	01	H1418_007_0	4	6		01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H1418	007	0	1	04	01	H1418_007_0	4	5		01	0000000000000000000000000000010000000		2		2			2		2		1		0		50			
H1418	008	0	1	04	01	H1418_008_0	3	1		11	0000000000000000000000010000000000000	000000100000000000000000	2		1	0.00	0.00	2		2		2							
H1418	008	0	1	04	01	H1418_008_0	3	2		01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H1418	008	0	1	04	01	H1418_008_0	3	7		10		000000000010000010100000	2		2			2		2		1		50		50			
H1418	008	0	1	04	01	H1418_008_0	3	6		11	0111111111111111111101100111001111111	000000000000000100000000	2		2			2		2		1		30		30			
H1418	008	0	1	04	01	H1418_008_0	3	5		01	0000000000000000000010000000000000000		2		2			2		2		1		20		30			
H1418	008	0	1	04	01	H1418_008_0	3	4		01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H1418	008	0	1	04	01	H1418_008_0	3	3		01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H1418	008	0	1	04	01	H1418_008_0	3	8		10		000000000100000000000000	1	25.00	2			2		2		1		50		50			
H1509	001	0	1	04	01	H1509_001_0	2	13	Group 13	01	0000000000001000000000000000000000000		2		1	30.00	60.00	2		2		2							
H1509	001	0	1	04	01	H1509_001_0	2	12	Group 12	01	0000010000000000000000000100000000000		2		2			2		2		1		50		50			
H1509	001	0	1	04	01	H1509_001_0	2	11	Group 11	01	0000000000000000000000000000010000000		2		2			2		2		1		0		40			
H1509	001	0	1	04	01	H1509_001_0	2	10	Group 10	11	0000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H1509	001	0	1	04	01	H1509_001_0	2	1	Group 1	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H1509	001	0	1	04	01	H1509_001_0	2	14	Group 14	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H1509	001	0	1	04	01	H1509_001_0	2	9	Group 9	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H1509	001	0	1	04	01	H1509_001_0	2	3	Group 3	11	0000000000000000000011000011001110010	000000000000000100000000	2		2			2		2		1		40		40			
H1509	001	0	1	04	01	H1509_001_0	2	4	Group 4	01	0000000000000001111100000000000000000		2		1	13.00	21.00	2		1	2	1		40		40	1	30.00	60.00
H1509	001	0	1	04	01	H1509_001_0	2	5	Group 5	10		000000000000000000100000	2		2			2		2		1		75		75			
H1509	001	0	1	04	01	H1509_001_0	2	6	Group 6	01	0000100000000000000000000000000000000		2		1	75.00	75.00	2		2		2							
H1509	001	0	1	04	01	H1509_001_0	2	7	Group 7	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H1509	001	0	1	04	01	H1509_001_0	2	8	Group 8	01	0000000000100100000000100000000000000		2		1	35.00	45.00	2		2		2							
H1509	001	0	1	04	01	H1509_001_0	2	2	Group 2	11	0111000111010010000000000000000001101	000001000000000000001010	2		1	60.00	60.00	2		2		2							
H1509	009	0	1	04	01	H1509_009_0	2	13	Group 13	01	0000000000001000000000000000000000000		2		1	35.00	60.00	2		2		2							
H1509	009	0	1	04	01	H1509_009_0	2	12	Group 12	01	0000010000000000000000000100000000000		2		2			2		2		1		50		50			
H1509	009	0	1	04	01	H1509_009_0	2	11	Group 11	01	0000000000000000000000000000010000000		2		2			2		2		1		0		40			
H1509	009	0	1	04	01	H1509_009_0	2	10	Group 10	11	0000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H1509	009	0	1	04	01	H1509_009_0	2	1	Group 1	01	0000001000000000000000000000000000000		2		1	35.00	35.00	2		2		2							
H1509	009	0	1	04	01	H1509_009_0	2	2	Group 2	11	0111000111010010000000000000000001101	000001000000000000001010	2		1	60.00	60.00	2		2		2							
H1509	009	0	1	04	01	H1509_009_0	2	9	Group 9	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H1509	009	0	1	04	01	H1509_009_0	2	8	Group 8	01	0000000000100100000000100000000000000		2		1	35.00	45.00	2		2		2							
H1509	009	0	1	04	01	H1509_009_0	2	7	Group 7	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H1509	009	0	1	04	01	H1509_009_0	2	6	Group 6	01	0000100000000000000000000000000000000		2		1	75.00	75.00	2		2		2							
H1509	009	0	1	04	01	H1509_009_0	2	5	Group 5	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H1509	009	0	1	04	01	H1509_009_0	2	4	Group 4	01	0000000000000001111100000000000000000		2		1	13.00	21.00	2		1	2	1		40		40	1	35.00	60.00
H1509	009	0	1	04	01	H1509_009_0	2	3	Group 3	11	0000000000000000000011000011001110010	000000000000000100000000	2		2			2		2		1		40		40			
H1509	010	0	1	04	01	H1509_010_0	2	1	Group 1	01	0000001000000000000000000000000000000		2		1	25.00	25.00	2		2		2							
H1509	010	0	1	04	01	H1509_010_0	2	10	Group 10	11	0000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H1509	010	0	1	04	01	H1509_010_0	2	11	Group 11	01	0000000000000000000000000000010000000		2		2			2		2		1		0		40			
H1509	010	0	1	04	01	H1509_010_0	2	12	Group 12	01	0000010000000000000000000100000000000		2		2			2		2		1		50		50			
H1509	010	0	1	04	01	H1509_010_0	2	13	Group 13	01	0000000000001000000000000000000000000		2		1	25.00	60.00	2		2		2							
H1509	010	0	1	04	01	H1509_010_0	2	8	Group 8	01	0000000000100100000000100000000000000		2		1	35.00	45.00	2		2		2							
H1509	010	0	1	04	01	H1509_010_0	2	9	Group 9	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H1509	010	0	1	04	01	H1509_010_0	2	6	Group 6	01	0000100000000000000000000000000000000		2		1	75.00	75.00	2		2		2							
H1509	010	0	1	04	01	H1509_010_0	2	5	Group 5	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H1509	010	0	1	04	01	H1509_010_0	2	4	Group 4	01	0000000000000001111100000000000000000		2		1	13.00	21.00	2		1	2	1		40		40	1	25.00	60.00
H1509	010	0	1	04	01	H1509_010_0	2	3	Group 3	11	0000000000000000000011000011001110010	000000000000000100000000	2		2			2		2		1		40		40			
H1509	010	0	1	04	01	H1509_010_0	2	2	Group 2	11	0111000111010010000000000000000001101	000001000000000000001010	2		1	60.00	60.00	2		2		2							
H1509	010	0	1	04	01	H1509_010_0	2	7	Group 7	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H1509	011	0	1	04	01	H1509_011_0	2	7	Group 7	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H1509	011	0	1	04	01	H1509_011_0	2	8	Group 8	01	0000000000100100000000100000000000000		2		1	35.00	45.00	2		2		2							
H1509	011	0	1	04	01	H1509_011_0	2	9	Group 9	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H1509	011	0	1	04	01	H1509_011_0	2	1	Group 1	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H1509	011	0	1	04	01	H1509_011_0	2	10	Group 10	11	0000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H1509	011	0	1	04	01	H1509_011_0	2	11	Group 11	01	0000000000000000000000000000010000000		2		2			2		2		1		0		40			
H1509	011	0	1	04	01	H1509_011_0	2	12	Group 12	01	0000010000000000000000000100000000000		2		2			2		2		1		50		50			
H1509	011	0	1	04	01	H1509_011_0	2	13	Group 13	01	0000000000001000000000000000000000000		2		1	30.00	60.00	2		2		2							
H1509	011	0	1	04	01	H1509_011_0	2	2	Group 2	11	0111000111010010000000000000000001101	000001000000000000001010	2		1	60.00	60.00	2		2		2							
H1509	011	0	1	04	01	H1509_011_0	2	3	Group 3	11	0000000000000000000011000011001110010	000000000000000100000000	2		2			2		2		1		40		40			
H1509	011	0	1	04	01	H1509_011_0	2	4	Group 4	01	0000000000000001111100000000000000000		2		1	13.00	21.00	2		1	2	1		40		40	1	30.00	60.00
H1509	011	0	1	04	01	H1509_011_0	2	5	Group 5	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H1509	011	0	1	04	01	H1509_011_0	2	6	Group 6	01	0000100000000000000000000000000000000		2		1	75.00	75.00	2		2		2							
H1509	801	0	1	04	01	H1509_801_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1509	801	0	1	04	01	H1509_801_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1509	803	0	1	04	01	H1509_803_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1509	803	0	1	04	01	H1509_803_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1509	804	0	1	04	01	H1509_804_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1509	804	0	1	04	01	H1509_804_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1509	806	0	2	04	01	H1509_806_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1509	806	0	2	04	01	H1509_806_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1509	807	0	2	04	01	H1509_807_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1509	807	0	2	04	01	H1509_807_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1509	808	0	2	04	01	H1509_808_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1509	808	0	2	04	01	H1509_808_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1509	809	0	1	04	01	H1509_809_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1509	809	0	1	04	01	H1509_809_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1509	810	0	1	04	01	H1509_810_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1509	810	0	1	04	01	H1509_810_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1509	811	0	1	04	01	H1509_811_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1509	811	0	1	04	01	H1509_811_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1509	812	0	1	04	01	H1509_812_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1509	812	0	1	04	01	H1509_812_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1509	813	0	1	04	01	H1509_813_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
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H1509	819	0	1	04	01	H1509_819_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1509	819	0	1	04	01	H1509_819_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1509	821	0	1	04	01	H1509_821_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
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H1509	822	0	1	04	01	H1509_822_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
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H1509	823	0	1	04	01	H1509_823_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
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H1510	001	0	1	04	01	H1510_001_0	3	3		10		000000000000000000001000	1	40.00	1	0.00	0.00	2		2		2							
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H1510	004	0	1	04	01	H1510_004_0	3	2		10		000000000000000000000100	1	100.00	1	0.00	0.00	2		2		2							
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H1510	008	0	1	04	01	H1510_008_0	3	2		10		000000000000000000000100	1	100.00	1	0.00	0.00	2		2		2							
H1510	008	0	1	04	01	H1510_008_0	3	6		01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H1510	008	0	1	04	01	H1510_008_0	3	5		01	0000000000000000000000000000100000000		2		2			2		2		1		0		20			
H1510	008	0	1	04	01	H1510_008_0	3	4		01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H1510	008	0	1	04	01	H1510_008_0	3	3		10		000000000000000000001000	1	40.00	1	0.00	0.00	2		2		2							
H1510	008	0	1	04	01	H1510_008_0	3	7		01	0000000000000000000000000100000000000		2		2			2		2		1		20		20			
H1517	006	1	1	04	01	H1517_006_1	15	6	DME/ASC	01	0000000000000000000001000111000000000		2		2			2		2		1		30		30			
H1517	006	1	1	04	01	H1517_006_1	15	8	RADIOLOGY	01	0000000000000001000100000000000000000		2		1	115.00	185.00	2		1	2	2					1	30.00	50.00
H1517	006	1	1	04	01	H1517_006_1	15	7	Eye	10		000000000000000000001000	1	69.00	1	0.00	0.00	2		2		2							
H1517	006	1	1	04	01	H1517_006_1	15	5	$50	01	0111100111110110000000100000000000010		2		1	50.00	50.00	2		2		2							
H1517	006	1	1	04	01	H1517_006_1	15	4	PCP	01	0000001000001000000000000000000000000		2		1	30.00	30.00	2		2		2							
H1517	006	1	1	04	01	H1517_006_1	15	3	Outpatient Hospital	01	0000000000000000000010000000000000000		2		1	30.00	50.00	2		2		1		30		30			
H1517	006	1	1	04	01	H1517_006_1	15	2	20%	11	0000000000000000001000000000100000000	000000000000000000100000	2		2			2		2		1		20		20			
H1517	006	1	1	04	01	H1517_006_1	15	15	Diagnostic Radiological	01	0000000000000000010000000000000000000		2		1	165.00	185.00	2		1	2	2					1	30.00	50.00
H1517	006	1	1	04	01	H1517_006_1	15	14	Hearing Exams	01	0000000000000000000000000000000000001		2		1	50.00	50.00	2		2		2							
H1517	006	1	1	04	01	H1517_006_1	15	13	EYE EXAMS	01	0000000000000000000000000000000000100		2		1	0.00	50.00	2		2		2							
H1517	006	1	1	04	01	H1517_006_1	15	12	PREVENTIVE SERVICES	11	0000000000000000000000000000010000000	000000000000000100000000	2		1	0.00	50.00	2		2		2							
H1517	006	1	1	04	01	H1517_006_1	15	11	30%	01	0000000000000000000000000000000010000		2		2			2		2		1		30		30			
H1517	006	1	1	04	01	H1517_006_1	15	9	LABS	01	0000000000000000100000000000000000000		2		1	30.00	30.00	2		1	2	2					1	30.00	50.00
H1517	006	1	1	04	01	H1517_006_1	15	1	$0	11	0000010000000000000000010000001101000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H1517	006	1	1	04	01	H1517_006_1	15	10	Ambulance	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H1517	006	2	1	04	01	H1517_006_2	15	3	Outpatient Hospital	01	0000000000000000000010000000000000000		2		1	30.00	50.00	2		2		1		30		30			
H1517	006	2	1	04	01	H1517_006_2	15	4	PCP	01	0000001000001000000000000000000000000		2		1	30.00	30.00	2		2		2							
H1517	006	2	1	04	01	H1517_006_2	15	5	$50	01	0111100111110110000000100000000000011		2		1	50.00	50.00	2		2		2							
H1517	006	2	1	04	01	H1517_006_2	15	6	DME/ASC	01	0000000000000000000001000111000000000		2		2			2		2		1		30		30			
H1517	006	2	1	04	01	H1517_006_2	15	7	Eye	10		000000000000000000001000	1	69.00	1	0.00	0.00	2		2		2							
H1517	006	2	1	04	01	H1517_006_2	15	8	RADIOLOGY	01	0000000000000001000100000000000000000		2		1	115.00	185.00	2		1	2	2					1	30.00	50.00
H1517	006	2	1	04	01	H1517_006_2	15	9	LABS	01	0000000000000000100000000000000000000		2		1	30.00	30.00	2		1	2	2					1	30.00	50.00
H1517	006	2	1	04	01	H1517_006_2	15	1	$0	11	0000010000000000000000010000001101000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H1517	006	2	1	04	01	H1517_006_2	15	10	Ambulance	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H1517	006	2	1	04	01	H1517_006_2	15	11	30%	01	0000000000000000000000000000000010000		2		2			2		2		1		30		30			
H1517	006	2	1	04	01	H1517_006_2	15	12	PREVENTIVE SERVICES	11	0000000000000000000000000000010000000	000000000000000100000000	2		1	0.00	50.00	2		2		2							
H1517	006	2	1	04	01	H1517_006_2	15	13	EYE EXAMS	01	0000000000000000000000000000000000100		2		1	0.00	50.00	2		2		2							
H1517	006	2	1	04	01	H1517_006_2	15	14	Preventive  Dental	10		000000000000000000100000	2		2			2		2		1		20		20			
H1517	006	2	1	04	01	H1517_006_2	15	15	Diagnostic Radiological	01	0000000000000000010000000000000000000		2		1	165.00	185.00	2		1	2	2					1	30.00	50.00
H1517	006	2	1	04	01	H1517_006_2	15	2	20%	01	0000000000000000001000000000100000000		2		2			2		2		1		20		20			
H1517	006	4	1	04	01	H1517_006_4	15	8	RADIOLOGY	01	0000000000000001000100000000000000000		2		1	115.00	185.00	2		1	2	2					1	30.00	50.00
H1517	006	4	1	04	01	H1517_006_4	15	9	LABS	01	0000000000000000100000000000000000000		2		1	30.00	30.00	2		1	2	2					1	30.00	50.00
H1517	006	4	1	04	01	H1517_006_4	15	1	$0	11	0000010000000000000000010000001101000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H1517	006	4	1	04	01	H1517_006_4	15	10	Ambulance	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H1517	006	4	1	04	01	H1517_006_4	15	11	30%	01	0000000000000000000000000000000010000		2		2			2		2		1		30		30			
H1517	006	4	1	04	01	H1517_006_4	15	12	PREVENTIVE SERVICES	11	0000000000000000000000000000010000000	000000000000000100000000	2		1	0.00	50.00	2		2		2							
H1517	006	4	1	04	01	H1517_006_4	15	13	EYE EXAMS	01	0000000000000000000000000000000000100		2		1	0.00	50.00	2		2		2							
H1517	006	4	1	04	01	H1517_006_4	15	14	Preventive  Dental	10		000000000000000000100000	2		2			2		2		1		20		20			
H1517	006	4	1	04	01	H1517_006_4	15	15	Diagnostic Radiological	01	0000000000000000010000000000000000000		2		1	165.00	185.00	2		1	2	2					1	30.00	50.00
H1517	006	4	1	04	01	H1517_006_4	15	2	20%	01	0000000000000000001000000000100000000		2		2			2		2		1		20		20			
H1517	006	4	1	04	01	H1517_006_4	15	3	Outpatient Hospital	01	0000000000000000000010000000000000000		2		1	30.00	50.00	2		2		1		30		30			
H1517	006	4	1	04	01	H1517_006_4	15	4	PCP	01	0000001000001000000000000000000000000		2		1	30.00	30.00	2		2		2							
H1517	006	4	1	04	01	H1517_006_4	15	5	$50	01	0111100111110110000000100000000000011		2		1	50.00	50.00	2		2		2							
H1517	006	4	1	04	01	H1517_006_4	15	6	DME/ASC	01	0000000000000000000001000111000000000		2		2			2		2		1		30		30			
H1517	006	4	1	04	01	H1517_006_4	15	7	Eye	10		000000000000000000001000	1	69.00	1	0.00	0.00	2		2		2							
H1517	801	0	1	04	01	H1517_801_0	7	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1517	801	0	1	04	01	H1517_801_0	7	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1517	802	0	1	04	01	H1517_802_0	6	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1517	802	0	1	04	01	H1517_802_0	6	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1517	803	0	1	04	01	H1517_803_0	6	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1517	803	0	1	04	01	H1517_803_0	6	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1537	001	0	1	04	01	H1537_001_0	2	1	Group 1	11	0111001111011010000011000011001111111	000001000000000100001010	2		2			2		2		1		40		40			
H1537	001	0	1	04	01	H1537_001_0	2	10	Group 10	10		000000000000000000000001	1	300.00	1	0.00	0.00	2		2		2							
H1537	001	0	1	04	01	H1537_001_0	2	2	Group 2	11	0000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H1537	001	0	1	04	01	H1537_001_0	2	3	Group 3	01	0000010000000000000000000100000000000		2		2			2		2		1		50		50			
H1537	001	0	1	04	01	H1537_001_0	2	9	Group 9	01	0000100000000000000000000000000000000		2		1	75.00	75.00	2		2		2							
H1537	001	0	1	04	01	H1537_001_0	2	5	Group 5	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H1537	001	0	1	04	01	H1537_001_0	2	6	Group 6	01	0000000000000000000000000000010000000		2		2			2		2		1		0		40			
H1537	001	0	1	04	01	H1537_001_0	2	7	Group 7	01	0000000000000001111100000000000000000		2		1	13.00	13.00	2		1	1	1	40	40	40	40	2		
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H1537	001	0	1	04	01	H1537_001_0	2	4	Group 4	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H1537	801	0	1	04	01	H1537_801_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1537	801	0	1	04	01	H1537_801_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1537	802	0	1	04	01	H1537_802_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1537	802	0	1	04	01	H1537_802_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1537	803	0	1	04	01	H1537_803_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1537	803	0	1	04	01	H1537_803_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1537	804	0	2	04	01	H1537_804_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1537	804	0	2	04	01	H1537_804_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1537	805	0	2	04	01	H1537_805_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1537	805	0	2	04	01	H1537_805_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1537	806	0	2	04	01	H1537_806_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1537	806	0	2	04	01	H1537_806_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1537	807	0	1	04	01	H1537_807_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1537	807	0	1	04	01	H1537_807_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1537	808	0	1	04	01	H1537_808_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1537	808	0	1	04	01	H1537_808_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1537	809	0	1	04	01	H1537_809_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1537	809	0	1	04	01	H1537_809_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1537	816	0	1	04	01	H1537_816_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1537	816	0	1	04	01	H1537_816_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1537	817	0	1	04	01	H1537_817_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1537	817	0	1	04	01	H1537_817_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1537	823	0	1	04	01	H1537_823_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1537	823	0	1	04	01	H1537_823_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1537	824	0	1	04	01	H1537_824_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1537	824	0	1	04	01	H1537_824_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1537	825	0	1	04	01	H1537_825_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1537	825	0	1	04	01	H1537_825_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1537	826	0	1	04	01	H1537_826_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1537	826	0	1	04	01	H1537_826_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1537	827	0	2	04	01	H1537_827_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1537	827	0	2	04	01	H1537_827_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1537	828	0	2	04	01	H1537_828_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1537	828	0	2	04	01	H1537_828_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1537	829	0	2	04	01	H1537_829_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1537	829	0	2	04	01	H1537_829_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1595	003	0	1	04	01	H1595_003_0	6	4	30% OON-SCS	01	0000000000000001111100000000000100100		2		2			2		1	1	1	30	30	30	30	2		
H1595	003	0	1	04	01	H1595_003_0	6	3		10		000000100000000010000000	2		2			2		2		2							
H1595	003	0	1	04	01	H1595_003_0	6	2	50% OON	11	0000000000000000000000000110000010000	000000000000000001001010	2		2			2		2		1		50		50			
H1595	003	0	1	04	01	H1595_003_0	6	1	30% OON	01	0111111111111110000011111001111001011		2		2			2		2		1		30		30			
H1595	004	0	1	04	01	H1595_004_0	6	4	30% OON-SCS	01	0000000000000001111100000000000100100		2		2			2		1	1	1	30	30	30	30	2		
H1595	004	0	1	04	01	H1595_004_0	6	3		10		000000100000000010000000	2		2			2		2		2							
H1595	004	0	1	04	01	H1595_004_0	6	2	50% OON	11	0000000000000000000000000110000010000	000000000000000001000010	2		2			2		2		1		50		50			
H1595	004	0	1	04	01	H1595_004_0	6	1	30% OON	01	0111111111111110000011111001111001011		2		2			2		2		1		30		30			
H1595	801	0	1	04	01	H1595_801_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1595	801	0	1	04	01	H1595_801_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1595	802	0	1	04	01	H1595_802_0	5	4	Group 4	01	0000010000000000100000000000010000000		2		2			2		2		2							
H1595	802	0	1	04	01	H1595_802_0	5	3	Group 3	01	0000000000100100000000000000000000000		2		2			2		2		1		35		35			
H1595	802	0	1	04	01	H1595_802_0	5	2	Group 2	01	0111101111011011011111111111101111111		2		2			2		2		1		20		20			
H1595	802	0	1	04	01	H1595_802_0	5	1	Group 1	10		000000000000000001000000	2		2			2		2		1		50		50			
H1595	804	0	1	04	01	H1595_804_0	5	2	Group 2	01	0111101111011011011111111111101111111		2		2			2		2		1		20		20			
H1595	804	0	1	04	01	H1595_804_0	5	1	Group 1	10		000000000000000001000000	2		2			2		2		1		50		50			
H1595	804	0	1	04	01	H1595_804_0	5	3	Group 3	01	0000000000100100000000000000000000000		2		2			2		2		1		35		35			
H1595	804	0	1	04	01	H1595_804_0	5	4	Group 4	01	0000010000000000100000000000010000000		2		2			2		2		2							
H1607	012	0	1	04	01	H1607_012_0	15	15	Diagnostic Radiological	01	0000000000000000010000000000000000000		2		1	160.00	180.00	2		1	2	2					1	30.00	50.00
H1607	012	0	1	04	01	H1607_012_0	15	4	PCP	01	0000001000001000000000000000000000000		2		1	30.00	30.00	2		2		2							
H1607	012	0	1	04	01	H1607_012_0	15	13	EYE EXAMS	10		000000000000000000001000	1	69.00	1	0.00	0.00	2		2		2							
H1607	012	0	1	04	01	H1607_012_0	15	12	PREVENTIVE SERVICES	11	0000000000000000000000000000010000100	000000000000000100000000	2		1	0.00	45.00	2		2		2							
H1607	012	0	1	04	01	H1607_012_0	15	11	20%	11	0000000000000000000000000000100010000	000000000000000000100000	2		2			2		2		1		20		20			
H1607	012	0	1	04	01	H1607_012_0	15	10	Ambulance Services	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
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H1666	004	0	1	04	01	H1666_004_0	10	1	40% Coinsurance	11	0111111111111111111111110111011011111	000000000000000100000010	2		2			2		2		1		40		40			
H1666	004	0	1	04	01	H1666_004_0	10	2	$200  Copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H1666	004	0	1	04	01	H1666_004_0	10	7	Hearing Aids	10		000000000000000000000001	1	1000.00	2			2		2		2							
H1666	004	0	1	04	01	H1666_004_0	10	6	Vision Eyewear - Frames	10		000000000000000000000100	1	100.00	2			2		2		2							
H1666	004	0	1	04	01	H1666_004_0	10	5	Vision Eye Exam	10		000000000000000000001000	1	40.00	2			2		2		2							
H1666	004	0	1	04	01	H1666_004_0	10	4	0 Copay/ 0 Coinsurance	11	0000000000000000000000000000000100000	000000000000000010000000	2		2			2		2		2							
H1666	004	0	1	04	01	H1666_004_0	10	3	20% Coinsurance	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H1666	005	0	1	04	01	H1666_005_0	10	2	$200  Copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H1666	005	0	1	04	01	H1666_005_0	10	1	40% Coinsurance	11	0111111111111111111111110111011011111	000000000000000100000010	2		2			2		2		1		40		40			
H1666	005	0	1	04	01	H1666_005_0	10	3	20% Coinsurance	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H1666	005	0	1	04	01	H1666_005_0	10	4	0 Copay/ 0 Coinsurance	11	0000000000000000000000000000000100000	000000000000000010000000	2		2			2		2		2							
H1666	005	0	1	04	01	H1666_005_0	10	5	Vision Eye Exam	10		000000000000000000001000	1	40.00	2			2		2		2							
H1666	005	0	1	04	01	H1666_005_0	10	6	Vision Eyewear - Frames	10		000000000000000000000100	1	100.00	2			2		2		2							
H1666	005	0	1	04	01	H1666_005_0	10	7	Hearing Aids	10		000000000000000000000001	1	1000.00	2			2		2		2							
H1666	006	0	1	04	01	H1666_006_0	10	2	$200  Copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H1666	006	0	1	04	01	H1666_006_0	10	1	40% Coinsurance	11	0111111111111111111111110111011011111	000000000000000100000010	2		2			2		2		1		40		40			
H1666	006	0	1	04	01	H1666_006_0	10	3	20% Coinsurance	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H1666	006	0	1	04	01	H1666_006_0	10	7	Hearing Aids	10		000000000000000000000001	1	1000.00	2			2		2		2							
H1666	006	0	1	04	01	H1666_006_0	10	6	Vision Eyewear - Frames	10		000000000000000000000100	1	100.00	2			2		2		2							
H1666	006	0	1	04	01	H1666_006_0	10	5	Vision Eye Exam	10		000000000000000000001000	1	40.00	2			2		2		2							
H1666	006	0	1	04	01	H1666_006_0	10	4	0 Copay/ 0 Coinsurance	11	0000000000000000000000000000000100000	000000000000000010000000	2		2			2		2		2							
H1666	801	0	1	04	01	H1666_801_0	5	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
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H1716	001	0	1	04	01	H1716_001_0	3	3		01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H1716	001	0	1	04	01	H1716_001_0	3	2		10		000000000000000000001000	1	40.00	1	0.00	0.00	2		2		2							
H1716	001	0	1	04	01	H1716_001_0	3	1		11	0000000000000000000000010000000000010	000000100000000000000000	2		1	0.00	0.00	2		2		2							
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H1716	001	0	1	04	01	H1716_001_0	3	9		10		000000000100000000000000	1	30.00	2			2		2		1		50		50			
H1716	001	0	1	04	01	H1716_001_0	3	6		01	0000000000000000000010000000000010000		2		2			2		2		1		20		30			
H1716	001	0	1	04	01	H1716_001_0	3	7		11	0111111111111111111101100111001101101	000000000000000100000000	2		2			2		2		1		30		30			
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H1716	020	0	1	04	01	H1716_020_0	3	10		10		000000000100000000000000	1	25.00	2			2		2		1		50		50			
H1716	020	0	1	04	01	H1716_020_0	3	1		11	0000000000000000000000010000000000010	000000100000000000000000	2		1	0.00	0.00	2		2		2							
H1716	020	0	1	04	01	H1716_020_0	3	3		01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H1716	020	0	1	04	01	H1716_020_0	3	9		10		000000000010000010000000	2		2			2		2		1		50		50			
H1716	020	0	1	04	01	H1716_020_0	3	8		11	0111111111111111111101100011001101101	000000000000000100000000	2		2			2		2		1		30		30			
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H1716	020	0	1	04	01	H1716_020_0	3	6		01	0000000000000000000000000100000000000		2		2			2		2		1		20		20			
H1716	020	0	1	04	01	H1716_020_0	3	5		01	0000000000000000000000000000010000000		2		2			2		2		1		0		50			
H1716	020	0	1	04	01	H1716_020_0	3	4		01	0000000000000000000000000000100000000		2		2			2		2		1		0		20			
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H1717	009	0	1	04	01	H1717_009_0	5	3	Group 3	01	0000000000000000000000001000100000000		2		2			2		2		1		20		20			
H1717	009	0	1	04	01	H1717_009_0	5	2	Group 2	01	0000000000000000000000000000000000010		2		1	0.00	0.00	2		2		2							
H1717	009	0	1	04	01	H1717_009_0	5	1	Group 1	11	0111111111111110000011110111001111101	000001100000000000001000	2		2			2		2		1		30		30			
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H1846	001	0	1	04	01	H1846_001_0	8	12	#12 DME Medicare Part B Rx Drugs	01	0000000000000000000000000110000010000		2		2			2		2		1		20		20			
H1846	001	0	1	04	01	H1846_001_0	8	11	#11 Ambulance Services	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H1846	001	0	1	04	01	H1846_001_0	8	14	#14 Ambulatory Surgical Center (ASC)	01	0000000000000000000001000000000000000		2		1	300.00	300.00	2		2		2							
H1846	001	0	1	04	01	H1846_001_0	8	15	#15 Outpatient Hospital Services	01	0000000000000000000010000000000000000		2		1	0.00	300.00	2		2		2							
H1846	001	0	1	04	01	H1846_001_0	8	2	#2 Preventative Services / Lab Services	11	0000000000000000100000000000011100000	000000000000000110000000	2		1	0.00	0.00	2		2		2							
H1846	001	0	1	04	01	H1846_001_0	8	3	#3 Primary Care Physician / Chiropractic	01	0000001100000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H1846	001	0	1	04	01	H1846_001_0	8	4	#4 End Stage Renal	01	0000000000000000000000000000100000000		2		1	30.00	30.00	2		2		2							
H1846	001	0	1	04	01	H1846_001_0	8	5	#5 Eye Exam	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	40.00	2		2		2							
H1846	001	0	1	04	01	H1846_001_0	8	6	#6 Physician Speciality Services	11	0000000001010000000000000000000001001	000000000000000000000010	2		1	40.00	40.00	2		2		2							
H1846	001	0	1	04	01	H1846_001_0	8	7	#7 Other Health Care Professionals	01	0000000000001000000000000000000000000		2		1	20.00	40.00	2		2		2							
H1846	001	0	1	04	01	H1846_001_0	8	8	#8 Cardiac Rehab	01	0111000000000000000000000000000000000		2		1	40.00	60.00	2		2		2							
H1846	001	0	1	04	01	H1846_001_0	8	9	#9 Outpatient Services	01	0000100010100110011100100000000000000		2		1	60.00	60.00	2		2		2							
H1846	001	0	1	04	01	H1846_001_0	8	13	#13 Diabetes Supplies and Services	01	0000000000000000000000000001000000000		2		2			2		2		1		0		20			
H1846	001	0	1	04	01	H1846_001_0	8	10	#10 OP Diagnostic Procedures / Test	01	0000000000000001000000000000000000000		2		1	0.00	60.00	2		2		2							
H1846	001	0	1	04	01	H1846_001_0	8	1	#1 Zero Cost Share	11	0000010000000000000000010000000000010	000000100000000000000000	2		2			2		2		2							
H1846	003	0	1	04	01	H1846_003_0	9	12	#12 DME / Medicare Part B Rx Drugs	01	0000000000000000000000000110000010000		2		2			2		2		1		20		20			
H1846	003	0	1	04	01	H1846_003_0	9	1	#1 Zero Cost Sharing	11	0000010000000000000000010000000000010	000000100000000000000000	2		2			2		2		2							
H1846	003	0	1	04	01	H1846_003_0	9	14	#14 Ambulance Services	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H1846	003	0	1	04	01	H1846_003_0	9	15	#15 OP Hospital  and ASC Services	01	0000000000000000000011000000000000000		2		1	0.00	300.00	2		2		2							
H1846	003	0	1	04	01	H1846_003_0	9	2	#2 Preventative / Education / Training	11	0000000000000000000000000000011100000	000000000000000110000000	2		1	0.00	0.00	2		2		2							
H1846	003	0	1	04	01	H1846_003_0	9	3	#3 Chiropractic Services	01	0000000100000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H1846	003	0	1	04	01	H1846_003_0	9	4	#4 End Stage Renal	01	0000000000000000000000000000100000000		2		1	30.00	30.00	2		2		2							
H1846	003	0	1	04	01	H1846_003_0	9	5	#5 Eye Exam	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	45.00	2		2		2							
H1846	003	0	1	04	01	H1846_003_0	9	6	#6 Physician Speciality Services	11	0000000001110100000000100000000001001	000000000000000000000010	2		1	45.00	45.00	2		2		2							
H1846	003	0	1	04	01	H1846_003_0	9	7	#7 Other Health Care Professionals	01	0000000000001000000000000000000000000		2		1	25.00	45.00	2		2		2							
H1846	003	0	1	04	01	H1846_003_0	9	8	#8 Cardiac Rehab	01	0111000000000000000000000000000000000		2		1	45.00	65.00	2		2		2							
H1846	003	0	1	04	01	H1846_003_0	9	9	#9 Primary Care Physician	01	0000001000000000000000000000000000000		2		1	25.00	25.00	2		2		2							
H1846	003	0	1	04	01	H1846_003_0	9	13	#13 Diabetic Supplies and Services	01	0000000000000000000000000001000000000		2		2			2		2		1		0		20			
H1846	003	0	1	04	01	H1846_003_0	9	10	#10 Lab Test	01	0000000000000000100000000000000000000		2		1	15.00	15.00	2		2		2							
H1846	003	0	1	04	01	H1846_003_0	9	11	#11 Outpatient Services	01	0000100010000011011100000000000000000		2		1	65.00	65.00	2		2		2							
H1846	801	0	1	04	01	H1846_801_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1846	801	0	1	04	01	H1846_801_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H1846	802	0	1	04	01	H1846_802_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H1846	802	0	1	04	01	H1846_802_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2001	001	0	1	04	01	H2001_001_0	4	1	Group 1	01	0000001000000000000000000000000000000		2		1	35.00	35.00	2		2		2							
H2001	001	0	1	04	01	H2001_001_0	4	10	Group 10	11	0000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H2001	001	0	1	04	01	H2001_001_0	4	9	Group 9	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H2001	001	0	1	04	01	H2001_001_0	4	8	Group 8	01	0000000000100100000000100000000000000		2		1	35.00	45.00	2		2		2							
H2001	001	0	1	04	01	H2001_001_0	4	7	Group 7	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H2001	001	0	1	04	01	H2001_001_0	4	11	Group 11	01	0000000000000000000000000000010000000		2		2			2		2		1		0		40			
H2001	001	0	1	04	01	H2001_001_0	4	12	Group 12	01	0000010000000000000000000100000000000		2		2			2		2		1		50		50			
H2001	001	0	1	04	01	H2001_001_0	4	13	Group 13	01	0000000000001000000000000000000000000		2		1	35.00	50.00	2		2		2							
H2001	001	0	1	04	01	H2001_001_0	4	2	Group 2	11	0111000111010010000000000000000001101	000001000000000000001010	2		1	50.00	50.00	2		2		2							
H2001	001	0	1	04	01	H2001_001_0	4	3	Group 3	11	0000000000000000000011000011001110010	000000000000000100000000	2		2			2		2		1		40		40			
H2001	001	0	1	04	01	H2001_001_0	4	4	Group 4	01	0000000000000001111100000000000000000		2		1	13.00	21.00	2		1	2	1		40		40	1	35.00	50.00
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H2001	001	0	1	04	01	H2001_001_0	4	6	Group 6	01	0000100000000000000000000000000000000		2		1	75.00	75.00	2		2		2							
H2001	816	0	1	04	01	H2001_816_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
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H2001	817	0	1	04	01	H2001_817_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
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H2001	818	0	1	04	01	H2001_818_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
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H2001	820	0	2	04	01	H2001_820_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
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H2001	821	0	2	04	01	H2001_821_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
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H2001	822	0	1	04	01	H2001_822_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2001	822	0	1	04	01	H2001_822_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2001	823	0	1	04	01	H2001_823_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
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H2001	824	0	1	04	01	H2001_824_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
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H2001	825	0	1	04	01	H2001_825_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
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H2001	826	0	1	04	01	H2001_826_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
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H2001	827	0	1	04	01	H2001_827_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2001	827	0	1	04	01	H2001_827_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2001	828	0	1	04	01	H2001_828_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2001	828	0	1	04	01	H2001_828_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2001	829	0	1	04	01	H2001_829_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2001	829	0	1	04	01	H2001_829_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2001	830	0	1	04	01	H2001_830_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2001	830	0	1	04	01	H2001_830_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2001	831	0	1	04	01	H2001_831_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2001	831	0	1	04	01	H2001_831_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2001	832	0	2	04	01	H2001_832_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2001	832	0	2	04	01	H2001_832_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2001	833	0	2	04	01	H2001_833_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2001	833	0	2	04	01	H2001_833_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2001	834	0	2	04	01	H2001_834_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2001	834	0	2	04	01	H2001_834_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2029	001	0	1	04	01	H2029_001_0	7	4		01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H2029	001	0	1	04	01	H2029_001_0	7	5		01	0000000000000000000000000000100000000		2		2			2		2		1		0		20			
H2029	001	0	1	04	01	H2029_001_0	7	6		01	0000000000000000000010000000000000000		2		2			2		2		1		20		30			
H2029	001	0	1	04	01	H2029_001_0	7	7		11	0111111111111111101101100111011111111	000000000000000100000000	2		2			2		2		1		30		30			
H2029	001	0	1	04	01	H2029_001_0	7	3		10		000000000000000000001000	1	40.00	1	0.00	0.00	2		2		2							
H2029	001	0	1	04	01	H2029_001_0	7	2		10		000000000000000000000100	1	100.00	1	0.00	0.00	2		2		2							
H2029	001	0	1	04	01	H2029_001_0	7	10		10		000000000100000000000000	1	50.00	2			2		2		1		50		50			
H2029	001	0	1	04	01	H2029_001_0	7	1		11	0000000000000000000000010000000000000	000000100000000000000000	2		1	0.00	0.00	2		2		2							
H2029	001	0	1	04	01	H2029_001_0	7	8		01	0000000000000000010000000000000000000		2		2			2		1	1	1	30	30	30	30	2		
H2029	001	0	1	04	01	H2029_001_0	7	9		10		000000000010000010110000	2		2			2		2		1		50		50			
H2029	801	0	1	04	01	H2029_801_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2029	801	0	1	04	01	H2029_801_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2029	802	0	1	04	01	H2029_802_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2029	802	0	1	04	01	H2029_802_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2029	803	0	1	04	01	H2029_803_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2029	803	0	1	04	01	H2029_803_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2029	805	0	2	04	01	H2029_805_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2029	805	0	2	04	01	H2029_805_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2029	806	0	2	04	01	H2029_806_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2029	806	0	2	04	01	H2029_806_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2029	807	0	2	04	01	H2029_807_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2029	807	0	2	04	01	H2029_807_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2111	001	0	1	04	01	H2111_001_0	5	1	Group 1	11	0111111111111110000011110111001111101	000001100000000000001010	2		2			2		2		1		30		30			
H2111	001	0	1	04	01	H2111_001_0	5	9	Group 9	10		000000000000000000100000	1	1000.00	1	0.00	0.00	2		2		2							
H2111	001	0	1	04	01	H2111_001_0	5	8	Group 8	10		000000000100000000000000	1	65.00	1	0.00	0.00	2		2		2							
H2111	001	0	1	04	01	H2111_001_0	5	7	Group 7	01	0000000000000001111100000000000000000		2		2			2		1	1	1	30	0	30	30	2		
H2111	001	0	1	04	01	H2111_001_0	5	6	Group 6	10		000000000000000000000001	1	1200.00	1	0.00	0.00	2		2		2							
H2111	001	0	1	04	01	H2111_001_0	5	5	Group 5	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H2111	001	0	1	04	01	H2111_001_0	5	4	Group 4	10		000000010000000000000000	2		2			2		2		1		75		75			
H2111	001	0	1	04	01	H2111_001_0	5	3	Group 3	01	0000000000000000000000001000100000000		2		2			2		2		1		20		20			
H2111	001	0	1	04	01	H2111_001_0	5	2	Group 2	11	0000000000000000000000000000000000010	000000000000000000010000	2		1	0.00	0.00	2		2		2							
H2111	001	0	1	04	01	H2111_001_0	5	10	Group 10	10		000000000000000000000100	1	200.00	1	0.00	0.00	2		2		2							
H2111	008	0	1	04	01	H2111_008_0	3	5	Group 5	10		000000010000000000000000	2		2			2		2		1		75		75			
H2111	008	0	1	04	01	H2111_008_0	3	4	Group 4	11	0000000000000000000000000000000000010	000000000000000010010000	2		1	0.00	0.00	2		2		2							
H2111	008	0	1	04	01	H2111_008_0	3	3	Group 3	01	0000000000000000000000001000100000000		2		2			2		2		1		20		20			
H2111	008	0	1	04	01	H2111_008_0	3	2	Group 2	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H2111	008	0	1	04	01	H2111_008_0	3	9	Group 9	10		000000000000000000000100	1	150.00	1	0.00	0.00	2		2		2							
H2111	008	0	1	04	01	H2111_008_0	3	7	Group 7	10		000000000100000000000000	1	75.00	1	0.00	0.00	2		2		2							
H2111	008	0	1	04	01	H2111_008_0	3	6	Group 6	01	0000000000000001111100000000000000000		2		2			2		1	1	1	30	0	30	30	2		
H2111	008	0	1	04	01	H2111_008_0	3	8	Group 8	10		000000000000000000100000	1	1000.00	1	0.00	0.00	2		2		2							
H2111	008	0	1	04	01	H2111_008_0	3	1	Group 1	11	0111111111111110000011110111001111101	000001100000000000001000	2		2			2		2		1		30		30			
H2228	001	0	1	04	01	H2228_001_0	4	6	Group 6	01	0000000000000001111100000000000000000		2		2			2		1	1	1	30	0	30	30	2		
H2228	001	0	1	04	01	H2228_001_0	4	5	Group 5	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H2228	001	0	1	04	01	H2228_001_0	4	4	Group 4	10		000000010000000000000000	2		2			2		2		1		75		75			
H2228	001	0	1	04	01	H2228_001_0	4	3	Group 3	01	0000000000000000000000001000100000000		2		2			2		2		1		20		20			
H2228	001	0	1	04	01	H2228_001_0	4	1	Group 1	11	0111111111111110000011110111001111101	000001100000000000001000	2		2			2		2		1		30		30			
H2228	001	0	1	04	01	H2228_001_0	4	2	Group 2	01	0000000000000000000000000000000000010		2		1	0.00	0.00	2		2		2							
H2228	001	0	1	04	01	H2228_001_0	4	7	Group7	10		000000000000000000000100	1	150.00	1	0.00	0.00	2		2		2							
H2228	002	0	1	04	01	H2228_002_0	5	6	Group 6	01	0000000000000001111100000000000000000		2		2			2		1	1	1	30	0	30	30	2		
H2228	002	0	1	04	01	H2228_002_0	5	5	Group 5	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H2228	002	0	1	04	01	H2228_002_0	5	4	Group 4	10		000000010000000000000000	2		2			2		2		1		75		75			
H2228	002	0	1	04	01	H2228_002_0	5	3	Group 3	01	0000000000000000000000001000100000000		2		2			2		2		1		20		20			
H2228	002	0	1	04	01	H2228_002_0	5	2	Group 2	01	0000000000000000000000000000000000010		2		1	0.00	0.00	2		2		2							
H2228	002	0	1	04	01	H2228_002_0	5	1	Group 1	11	0111111111111110000011110111001111101	000001100000000000001000	2		2			2		2		1		30		30			
H2228	002	0	1	04	01	H2228_002_0	5	7	Group 7	10		000000000100000000000000	1	45.00	1	0.00	0.00	2		2		2							
H2228	002	0	1	04	01	H2228_002_0	5	8	Group 8	10		000000000000000000000100	1	100.00	1	0.00	0.00	2		2		2							
H2230	002	0	1	04	01	H2230_002_0	7	1		11	0111110010100110000011110111001000000	000000100000000000000000	2		2			2		2		1		20		20			
H2230	002	0	1	04	01	H2230_002_0	7	10		01	0000000000000000000000000000000100000		2		2			2		1	2	1		20		20	1	45.00	45.00
H2230	002	0	1	04	01	H2230_002_0	7	11		01	0000000000000001101100000000000000000		2		2			2		1	2	1		20		20	1	45.00	45.00
H2230	002	0	1	04	01	H2230_002_0	7	12		01	0000000000000000010000000000000000000		2		2			2		1	2	1		40		40	1	45.00	45.00
H2230	002	0	1	04	01	H2230_002_0	7	13		01	0000000000000000000000000000000000100		2		1	45.00	45.00	2		2		2							
H2230	002	0	1	04	01	H2230_002_0	7	2		11	0000001101011000000000000000000000001	000000000000000000101010	2		1	45.00	45.00	2		2		2							
H2230	002	0	1	04	01	H2230_002_0	7	9		10		000000000000000000000001	1	400.00	2			2		2		2							
H2230	002	0	1	04	01	H2230_002_0	7	4		11	0000000000000000000000000000000010010	000000000000000001000000	2		1	0.00	0.00	2		2		2							
H2230	002	0	1	04	01	H2230_002_0	7	5		01	0000000000000000000000000000010001000		2		1	45.00	45.00	2		2		1		20		20			
H2230	002	0	1	04	01	H2230_002_0	7	6		01	0000000000000000000000000000100000000		2		2			2		2		1		0		20			
H2230	002	0	1	04	01	H2230_002_0	7	7		10		000000000000000010000000	1	650.00	2			2		2		2							
H2230	002	0	1	04	01	H2230_002_0	7	8		10		000000000001000000000100	1	150.00	2			2		2		2							
H2230	002	0	1	04	01	H2230_002_0	7	3		01	0000000000000000000000001000000000000		2		1	0.00	100.00	2		2		2							
H2230	016	0	1	04	01	H2230_016_0	6	10	Group #10	01	0000000000000000010000000000000000000		2		1	150.00	150.00	2		1	2	2					1	20.00	40.00
H2230	016	0	1	04	01	H2230_016_0	6	1	Group #1	01	0111001110000010000000000000000000000		2		1	20.00	20.00	2		2		2							
H2230	016	0	1	04	01	H2230_016_0	6	11	Group #11	01	0000000000000000000000000000000100000		2		1	0.00	0.00	2		1	2	2					1	20.00	40.00
H2230	016	0	1	04	01	H2230_016_0	6	9	Group #9	01	0000000000000000000011000000000000000		2		1	200.00	200.00	2		2		2							
H2230	016	0	1	04	01	H2230_016_0	6	8	Group #8	01	0000000000000001100100000000000000000		2		1	20.00	20.00	2		1	2	2					1	20.00	40.00
H2230	016	0	1	04	01	H2230_016_0	6	7	Group #7	01	0000000000000000000000000110000000000		2		2			2		2		1		20		20			
H2230	016	0	1	04	01	H2230_016_0	6	6	Group #6	01	0000000000000000000000001000000000000		2		1	0.00	100.00	2		2		2							
H2230	016	0	1	04	01	H2230_016_0	6	5	Group #5	01	0000000000000000000000000000000000100		2		1	0.00	40.00	2		2		2							
H2230	016	0	1	04	01	H2230_016_0	6	4	Group #4	11	0000000001101100000000100000000001000	000000000000000000101000	2		1	40.00	40.00	2		2		2							
H2230	016	0	1	04	01	H2230_016_0	6	3	Group #3	11	0000000000010000000000000000000000001	000000000000000000000010	2		1	20.00	40.00	2		2		2							
H2230	016	0	1	04	01	H2230_016_0	6	2	Group #2	11	0000010000000000001000010001111010010	000000100000000001000000	2		1	0.00	0.00	2		2		2							
H2230	016	0	1	04	01	H2230_016_0	6	15	Group #15	10		000000000001000000000000	1	150.00	2			2		2		2							
H2230	016	0	1	04	01	H2230_016_0	6	14	Group #14	10		000000000000000000000100	1	150.00	2			2		2		2							
H2230	016	0	1	04	01	H2230_016_0	6	13	Group #13	10		000000000000000010000000	1	650.00	2			2		2		2							
H2230	016	0	1	04	01	H2230_016_0	6	12	Group #12	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
H2230	017	0	1	04	01	H2230_017_0	6	1		01	0000000000000000000000000110100000000		2		2			2		2		1		20		20			
H2230	017	0	1	04	01	H2230_017_0	6	10	Group #10	01	0000000000000000001000000000000000000		2		1	60.00	60.00	2		2		2							
H2230	017	0	1	04	01	H2230_017_0	6	15	Group #15	10		000000000001000000000000	1	150.00	2			2		2		2							
H2230	017	0	1	04	01	H2230_017_0	6	2		11	0000010000000000000000010001011110010	000000100000000001000000	2		1	0.00	0.00	2		2		2							
H2230	017	0	1	04	01	H2230_017_0	6	3		11	0111000001000000000000000000000001000	000000000000000000100000	2		1	45.00	45.00	2		2		2							
H2230	017	0	1	04	01	H2230_017_0	6	11	Group #11	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
H2230	017	0	1	04	01	H2230_017_0	6	12	Group #12	01	0000000000000000000100000000000000000		2		1	30.00	30.00	2		1	2	2					1	25.00	45.00
H2230	017	0	1	04	01	H2230_017_0	6	13	Group #13	01	0000000000011000000000000000000000001		2		1	25.00	45.00	2		2		2							
H2230	017	0	1	04	01	H2230_017_0	6	14	Group #14	01	0000000100000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H2230	017	0	1	04	01	H2230_017_0	6	9	Group #9	01	0000000000000000000000000000000000100		2		1	0.00	45.00	2		2		2							
H2230	017	0	1	04	01	H2230_017_0	6	8	Group #8	01	0000000000000000010011000000000000000		2		1	300.00	300.00	2		2		2							
H2230	017	0	1	04	01	H2230_017_0	6	7	Group #7	01	0000001000000001100000000000000000000		2		1	25.00	25.00	2		2		2							
H2230	017	0	1	04	01	H2230_017_0	6	6		10		000000000000000010000000	1	650.00	1	0.00	0.00	2		2		2							
H2230	017	0	1	04	01	H2230_017_0	6	5	Group #5	01	0000000000000000000000001000000000000		2		1	0.00	250.00	2		2		2							
H2230	017	0	1	04	01	H2230_017_0	6	4	Group #4	01	0000000010100110000000100000000000000		2		1	40.00	40.00	2		2		2							
H2230	801	0	1	04	01	H2230_801_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2230	801	0	1	04	01	H2230_801_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2230	809	0	1	04	01	H2230_809_0	5	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2230	809	0	1	04	01	H2230_809_0	5	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2322	004	0	1	04	01	H2322_004_0	9	2		01	0000100000100100000000100110000000010		2		2			2		2		1		50		50			
H2322	004	0	1	04	01	H2322_004_0	9	3		10		000000000000000010000000	1	40.00	2			2		2		2							
H2322	004	0	1	04	01	H2322_004_0	9	1		11	0111011111011011111111011001111111101	000000100000000000001010	2		2			2		2		1		20		20			
H2322	008	0	1	04	01	H2322_008_0	9	1		11	0111011111011011111111011001111111101	000000100000000000001010	2		2			2		2		1		25		25			
H2322	008	0	1	04	01	H2322_008_0	9	2		01	0000100000100100000000100110000000010		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	4		10		000000000000000000000100	1	120.00	2			2		2		1		50		50			
H2322	801	0	1	04	01	H2322_801_0	8	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2322	801	0	1	04	01	H2322_801_0	8	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2322	803	0	1	04	01	H2322_803_0	8	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2322	803	0	1	04	01	H2322_803_0	8	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2322	809	0	1	04	01	H2322_809_0	8	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2322	809	0	1	04	01	H2322_809_0	8	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2406	001	0	1	04	01	H2406_001_0	6	1	Group 1	11	0111111111111110000011110111001111101	000001100000000000001000	2		2			2		2		1		30		30			
H2406	001	0	1	04	01	H2406_001_0	6	2	Group 2	11	0000000000000000000000000000000000010	000000000000000000010000	2		1	0.00	0.00	2		2		2							
H2406	001	0	1	04	01	H2406_001_0	6	3	Group 3	01	0000000000000000000000001000100000000		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	5	Group 5	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H2406	001	0	1	04	01	H2406_001_0	6	6	Group 6	01	0000000000000001111100000000000000000		2		2			2		1	1	1	30	0	30	30	2		
H2406	001	0	1	04	01	H2406_001_0	6	9	Group 9	10		000000000000000000000100	1	150.00	1	0.00	0.00	2		2		2							
H2406	001	0	1	04	01	H2406_001_0	6	7	Group 7	10		000000000100000000000000	1	115.00	1	0.00	0.00	2		2		2							
H2406	001	0	1	04	01	H2406_001_0	6	8	Group 8	10		000000000000000000100000	1	250.00	1	0.00	0.00	2		2		2							
H2411	803	0	1	04	01	H2411_803_0	5	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2411	803	0	1	04	01	H2411_803_0	5	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2591	001	0	1	04	01	H2591_001_0	3	1	Office Visits	11	0111111111111111111100100000011111101	000000000000000100001010	2		2			2		2		1		30		30			
H2591	001	0	1	04	01	H2591_001_0	3	2	Renal Dialysis	11	0000000000000000000000010000100000000	000000100000000000000000	2		2			2		2		1		30		30			
H2591	001	0	1	04	01	H2591_001_0	3	3	Ambulance	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H2591	001	0	1	04	01	H2591_001_0	3	4	DME	01	0000000000000000000000000111000000000		2		2			2		2		1		30		30			
H2591	001	0	1	04	01	H2591_001_0	3	5	ASC	01	0000000000000000000011000000000000000		2		2			2		2		1		30		30			
H2591	001	0	1	04	01	H2591_001_0	3	6	Eye Wear	01	0000000000000000000000000000000000010		2		2			2		2		2							
H2591	001	0	1	04	01	H2591_001_0	3	7	Other Services	10		000000000000000010000000	2		1	0.00	50.00	2		2		2							
H2591	001	0	1	04	01	H2591_001_0	3	8	Preventive Dental	10		000000000000000000100000	2		1	0.00	20.00	2		2		2							
H2591	801	0	1	04	01	H2591_801_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2591	801	0	1	04	01	H2591_801_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2591	802	0	1	04	01	H2591_802_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2591	802	0	1	04	01	H2591_802_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2591	803	0	1	04	01	H2591_803_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2591	803	0	1	04	01	H2591_803_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2611	001	0	1	04	01	H2611_001_0	6	7	Out of Network-Fitness--Non Gym	10		000000000000000010000000	2		1	50.00	50.00	2		2		2							
H2611	001	0	1	04	01	H2611_001_0	6	8	Benefits w/separate office visit cost	01	0000000000000000011100000000000100100		2		2			2		1	1	1	30	30	30	30	2		
H2611	001	0	1	04	01	H2611_001_0	6	9	Medicare Eyeware	01	0000000000000000000000000000000000010		2		2			2		2		1		30		30			
H2611	001	0	1	04	01	H2611_001_0	6	6	Non-Medicare Dental	10		000000000000000000100000	1	500.00	2			2		2		1		30		30			
H2611	001	0	1	04	01	H2611_001_0	6	1	Out of Network Coinsurance Group 1	11	0111101111111111111111110111111111111	000001100000000000001010	2		2			2		2		1		30		30			
H2611	001	0	1	04	01	H2611_001_0	6	4	Out of Network Eyeware	10		000000000000000000000100	1	100.00	2			2		2		1		30		30			
H2611	001	0	1	04	01	H2611_001_0	6	3	Out of Network Fitness Copay--Gym	10		000000000000000010000000	2		1	50.00	50.00	2		2		2							
H2611	001	0	1	04	01	H2611_001_0	6	2	Out of Network Copay Group 1	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H2611	001	0	1	04	01	H2611_001_0	6	5	No Cost OON Group	01	0000010000000000000000000000000000000		2		2			2		2		1		0		0			
H2611	008	0	1	04	01	H2611_008_0	3	3	Group 3	11	0111101111111110000011110000111011111	000000100000000000001000	2		2			2		2		1		50		50			
H2611	008	0	1	04	01	H2611_008_0	3	5	Group 5	01	0000000000000000000000000111000000000		2		2			2		2		1		20		20			
H2611	008	0	1	04	01	H2611_008_0	3	6		01	0000000000000001111100000000000100000		2		2			2		1	1	1	50	50	50	50	2		
H2611	008	0	1	04	01	H2611_008_0	3	4	Group 4	10		000000000000000010000000	2		1	0.00	50.00	2		2		1		50		50			
H2611	008	0	1	04	01	H2611_008_0	3	2	Group 2	01	0000010000000000000000000000000000000		2		1	0.00	0.00	2		2		2							
H2611	008	0	1	04	01	H2611_008_0	3	1	Group 1	01	0000000000000000000000001000000000000		2		1	275.00	275.00	2		2		2							
H2611	018	0	1	04	01	H2611_018_0	3	2	Group 2	11	0111101111111110000011110000111011111	000000100000000000001000	2		2			2		2		1		45		45			
H2611	018	0	1	04	01	H2611_018_0	3	3	Group 3	01	0000010000000000000000000000000000000		2		1	0.00	0.00	2		2		2							
H2611	018	0	1	04	01	H2611_018_0	3	6	Group 6	01	0000000000000001111100000000000100000		2		2			2		1	1	1	45	45	45	45	2		
H2611	018	0	1	04	01	H2611_018_0	3	4	Group 4	10		000000000000000010000000	2		1	0.00	50.00	2		2		1		45		45			
H2611	018	0	1	04	01	H2611_018_0	3	1	Group 1	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H2611	018	0	1	04	01	H2611_018_0	3	5	Group 5	01	0000000000000000000000000111000000000		2		2			2		2		1		20		20			
H2611	807	0	1	04	01	H2611_807_0	1	3	Medicare Covered	01	0111101111011011111111111111101111111		2		2			2		2		1		20		20			
H2611	807	0	1	04	01	H2611_807_0	1	1	Home Health and Preventive Services	01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2611	807	0	1	04	01	H2611_807_0	1	2	Mental Health	01	0000000000100100000000000000000000000		2		2			2		2		1		35		35			
H2611	809	0	1	04	01	H2611_809_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H2611	809	0	1	04	01	H2611_809_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2611	824	0	1	04	01	H2611_824_0	1	3	Medicare Covered	01	0111101111011011111111111111101111111		2		2			2		2		1		20		20			
H2611	824	0	1	04	01	H2611_824_0	1	1	Home Health and Preventive Services	01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H2611	824	0	1	04	01	H2611_824_0	1	2	Mental Health	01	0000000000100100000000000000000000000		2		2			2		2		1		35		35			
H2676	001	0	1	04	01	H2676_001_0	5	4	$40-$60 Copay	01	0000000000000000000000000000011100001		2		1	40.00	60.00	2		2		2							
H2676	001	0	1	04	01	H2676_001_0	5	3	$60 Copay	01	0000000111010110000000000000000000000		2		1	60.00	60.00	2		2		2							
H2676	001	0	1	04	01	H2676_001_0	5	2	$40 Copay	01	0000011000000000000000000000000000000		2		1	40.00	40.00	2		2		2							
H2676	001	0	1	04	01	H2676_001_0	5	9	$0 Copay	10		000000000000000010000000	2		2			2		2		2							
H2676	001	0	1	04	01	H2676_001_0	5	1	30% Coinsurance	11	0111100000101000000011110111100011000	000000100000000000000000	2		2			2		2		1		30		30			
H2676	001	0	1	04	01	H2676_001_0	5	8	$250 Copay/20% Coinsurance	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		1		20		20			
H2676	001	0	1	04	01	H2676_001_0	5	5	30% Coinsurance	01	0000000000000001111100000000000000000		2		2			2		1	2	1		30		30	1	40.00	60.00
H2676	001	0	1	04	01	H2676_001_0	5	6	$0-$60 Copay	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	60.00	2		2		2							
H2676	001	0	1	04	01	H2676_001_0	5	7	0%-30%	01	0000000000000000000000000000000000010		2		2			2		2		1		0		30			
H2676	001	0	1	04	01	H2676_001_0	5	10	0%-30%	10		000000000000000000000100	1	100.00	2			2		2		1		0		30			
H2701	003	0	1	04	01	H2701_003_0	6	5	Diagnostic Tests Xrays Labs Radiology	01	0000000000000001101100000000000000000		2		1	50.00	50.00	2		2		2							
H2701	003	0	1	04	01	H2701_003_0	6	4	Ambulance	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H2701	003	0	1	04	01	H2701_003_0	6	3	Outpatient Services	01	0000000000000000010000000000000000000		2		1	200.00	200.00	2		2		2							
H2701	003	0	1	04	01	H2701_003_0	6	2	Outpatient Service/Surgery	01	0000000000000000000011000000000000000		2		1	500.00	500.00	2		2		2							
H2701	003	0	1	04	01	H2701_003_0	6	12	Provider Visits	01	0000001001000000000000000000000000000		2		1	50.00	50.00	2		2		2							
H2701	003	0	1	04	01	H2701_003_0	6	1	Provider Specialists	11	0000100110111110000000110000000001000	000000100000000000000000	2		1	50.00	50.00	2		2		2							
H2701	003	0	1	04	01	H2701_003_0	6	10	Preventive Services	11	0000010000000000000000000000010000000	000000000000000110000000	2		1	0.00	0.00	2		2		2							
H2701	003	0	1	04	01	H2701_003_0	6	6	Cardiac Pulmonary Rehab	11	0111000000000000000000000000001100000	011100000000000000000000	2		1	50.00	50.00	2		2		2							
H2701	003	0	1	04	01	H2701_003_0	6	9	Eye Exams	11	0000000000000000000000000000000000110	000000000000000000001000	2		1	50.00	50.00	2		2		2							
H2701	003	0	1	04	01	H2701_003_0	6	8	Part B Drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		20		20			
H2701	003	0	1	04	01	H2701_003_0	6	7	DME Prosthetics Diabetic Supplies	01	0000000000000000000000000111100000000		2		2			2		2		1		20		20			
H2701	003	0	1	04	01	H2701_003_0	6	11	Hearing Exams	01	0000000000000000000000000000000000001		2		1	50.00	50.00	2		2		2							
H2701	006	0	1	04	01	H2701_006_0	5	3	Outpatient Services	01	0000000000000000010000000000000000000		2		1	200.00	200.00	2		2		2							
H2701	006	0	1	04	01	H2701_006_0	5	4	Ambulance Services	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H2701	006	0	1	04	01	H2701_006_0	5	5	Diagnostic Tests Xrays Lab Radiology	01	0000000000000001101100000000000000000		2		1	50.00	50.00	2		2		2							
H2701	006	0	1	04	01	H2701_006_0	5	6	Cardiac Pulmonary Rehab	11	0111000000000000000000000000000000000	011100000000000000000000	2		1	50.00	50.00	2		2		2							
H2701	006	0	1	04	01	H2701_006_0	5	7	DME Prosthetics Diabetic Supplies	01	0000000000000000000000000111100000000		2		2			2		2		1		20		20			
H2701	006	0	1	04	01	H2701_006_0	5	8	Blood	11	0000000000000000000000010000000000000	000000100000000000000000	2		1	50.00	50.00	2		2		2							
H2701	006	0	1	04	01	H2701_006_0	5	9	Part B Drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		20		20			
H2701	006	0	1	04	01	H2701_006_0	5	11	Eye Exams	11	0000000000000000000000000000000000110	000000000000000000001000	2		1	50.00	50.00	2		2		2							
H2701	006	0	1	04	01	H2701_006_0	5	2	Outpatient Services/Surgery	01	0000000000000000000011000000000000000		2		1	500.00	500.00	2		2		2							
H2701	006	0	1	04	01	H2701_006_0	5	10	Preventive Services	11	0000010000000000000000000000010000000	000000000000000110000000	2		1	0.00	0.00	2		2		2							
H2701	006	0	1	04	01	H2701_006_0	5	1	Provider Specialists	11	0000101111111110000000110000001101001	000000100000000000000000	2		1	50.00	50.00	2		2		2							
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H2775	082	0	1	04	01	H2775_082_0	8	6		11	0000000000000001111100000000000100100	000000000000000000001000	2		2			2		1	1	1	20	20	20	20	1	10.00	35.00
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H2775	082	0	1	04	01	H2775_082_0	8	2		01	0000000100000000000000000000000000000		2		2			2		2		1		20		20			
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H3209	001	0	1	04	01	H3209_001_0	5	6	Group 6	01	0000000000000001111100000000000000000		2		2			2		1	1	1	30	0	30	30	2		
H3209	002	0	1	04	01	H3209_002_0	3	1	Group 1	11	0111111111111110000011110111001111101	000001100000000000001000	2		2			2		2		1		30		30			
H3209	002	0	1	04	01	H3209_002_0	3	2	Group 2	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H3209	002	0	1	04	01	H3209_002_0	3	3	Group 3	01	0000000000000000000000001000100000000		2		2			2		2		1		20		20			
H3209	002	0	1	04	01	H3209_002_0	3	7	Group 7	10		000000000000000000100000	1	2000.00	1	0.00	0.00	2		2		2							
H3209	002	0	1	04	01	H3209_002_0	3	6	Group 6	10		000000000100000000000000	1	90.00	1	0.00	0.00	2		2		2							
H3209	002	0	1	04	01	H3209_002_0	3	5	Group 5	01	0000000000000001111100000000000000000		2		2			2		1	1	1	30	0	30	30	2		
H3209	002	0	1	04	01	H3209_002_0	3	4	Group 4	11	0000000000000000000000000000000000010	000000000000000000010000	2		1	0.00	0.00	2		2		2							
H3209	002	0	1	04	01	H3209_002_0	3	8	Group 8	10		000000000000000000000100	1	150.00	1	0.00	0.00	2		2		2							
H3335	005	0	1	04	01	H3335_005_0	8	8	$55 Copayment - Specialist Services	11	0111000001011000000100000000000001111	000000000000000000001010	2		1	55.00	55.00	2		2		2							
H3335	005	0	1	04	01	H3335_005_0	8	7	$25 Copayment	01	0000001100000000000000000000000000000		2		1	25.00	25.00	2		2		2							
H3335	005	0	1	04	01	H3335_005_0	8	6	Supplemental Education/Wellness Programs	10		000000000000000010000000	2		2			2		2		2							
H3335	005	0	1	04	01	H3335_005_0	8	9	Preventive Dental	10		000000000000000000100000	2		2			2		2		2							
H3335	005	0	1	04	01	H3335_005_0	8	5	Preventive Services	01	0000000000000000000000000000010000000		2		1	0.00	25.00	2		2		1		30		30			
H3335	005	0	1	04	01	H3335_005_0	8	2	50% Coinsurance	01	0000100000000000000000000000000000000		2		2			2		2		1		50		50			
H3335	005	0	1	04	01	H3335_005_0	8	3	$225 Copayment	01	0000000000000000000000001000000000000		2		1	225.00	225.00	2		2		2							
H3335	005	0	1	04	01	H3335_005_0	8	4	PT/OT/ST	01	0000000010000010000000000000000000000		2		1	50.00	50.00	2		2		2							
H3335	005	0	1	04	01	H3335_005_0	8	1	30% Coinsurance	11	0000010000100101111011110111101110000	000000100000000100000000	2		2			2		2		1		30		30			
H3335	006	0	1	04	01	H3335_006_0	7	7	$20 Copayment	01	0000001100000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H3335	006	0	1	04	01	H3335_006_0	7	6	Supplemental Education/Wellness Programs	10		000000000000000010000000	2		2			2		2		2							
H3335	006	0	1	04	01	H3335_006_0	7	4	Specialist	11	0111000011011010000100000000000001111	000000000000000000001010	2		1	50.00	50.00	2		2		2							
H3335	006	0	1	04	01	H3335_006_0	7	5	Preventive Services	01	0000000000000000000000000000010000000		2		1	0.00	20.00	2		2		1		30		30			
H3335	006	0	1	04	01	H3335_006_0	7	8	Preventive Dental	10		000000000000000000100000	2		2			2		2		2							
H3335	006	0	1	04	01	H3335_006_0	7	3	$175 Copayment	01	0000000000000000000000001000000000000		2		1	175.00	175.00	2		2		2							
H3335	006	0	1	04	01	H3335_006_0	7	2	50% Coinsurance	01	0000100000000000000000000000000000000		2		2			2		2		1		50		50			
H3335	006	0	1	04	01	H3335_006_0	7	1	30% Coinsurance	11	0000010000100101111011110111101110000	000000100000000100000000	2		2			2		2		1		30		30			
H3335	014	0	1	04	01	H3335_014_0	7	1	30% Coinsurance	11	0000010000100101111011110111101110000	000000100000000100000000	2		2			2		2		1		30		30			
H3335	014	0	1	04	01	H3335_014_0	7	2	50% Coinsurance	01	0000100000000000000000000000000000000		2		2			2		2		1		50		50			
H3335	014	0	1	04	01	H3335_014_0	7	3	$225 Copayment	01	0000000000000000000000001000000000000		2		1	225.00	225.00	2		2		2							
H3335	014	0	1	04	01	H3335_014_0	7	4	PT/OT/ST	01	0000000010000010000000000000000000000		2		1	50.00	50.00	2		2		2							
H3335	014	0	1	04	01	H3335_014_0	7	9	Preventive Dental	10		000000000000000000100000	2		2			2		2		2							
H3335	014	0	1	04	01	H3335_014_0	7	7	$25 Copayment	01	0000001100000000000000000000000000000		2		1	25.00	25.00	2		2		2							
H3335	014	0	1	04	01	H3335_014_0	7	6	Supplemental Education/Wellness Programs	10		000000000000000010000000	2		2			2		2		2							
H3335	014	0	1	04	01	H3335_014_0	7	5	Preventive Services	01	0000000000000000000000000000010000000		2		1	0.00	25.00	2		2		1		30		30			
H3335	014	0	1	04	01	H3335_014_0	7	8	$55 Copayment - Specialist Services	11	0111000001011000000100000000000001111	000000000000000000001010	2		1	55.00	55.00	2		2		2							
H3335	015	0	1	04	01	H3335_015_0	7	3	$175 Copayment	01	0000000000000000000000001000000000000		2		1	175.00	175.00	2		2		2							
H3335	015	0	1	04	01	H3335_015_0	7	4	Specialist	11	0111000011011010000100000000000001111	000000000000000000001010	2		1	50.00	50.00	2		2		2							
H3335	015	0	1	04	01	H3335_015_0	7	5	Preventive Services	01	0000000000000000000000000000010000000		2		1	0.00	20.00	2		2		1		30		30			
H3335	015	0	1	04	01	H3335_015_0	7	6	Supplemental Education/Wellness Programs	10		000000000000000010000000	2		2			2		2		2							
H3335	015	0	1	04	01	H3335_015_0	7	7	$20 Copayment	01	0000001100000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H3335	015	0	1	04	01	H3335_015_0	7	8	Preventive Dental	10		000000000000000000100000	2		2			2		2		2							
H3335	015	0	1	04	01	H3335_015_0	7	1	30% Coinsurance	11	0000010000100101111011110111101110000	000000100000000100000000	2		2			2		2		1		30		30			
H3335	015	0	1	04	01	H3335_015_0	7	2	50% Coinsurance	01	0000100000000000000000000000000000000		2		2			2		2		1		50		50			
H3335	018	0	1	04	01	H3335_018_0	7	3	$300 Copayment	01	0000000000000000000000001000000000000		2		1	300.00	300.00	2		2		2							
H3335	018	0	1	04	01	H3335_018_0	7	2	50% Coinsurance	01	0000100000000000000000000000000000000		2		2			2		2		1		50		50			
H3335	018	0	1	04	01	H3335_018_0	7	1	30% Coinsurance	11	0111011111111111111111110111111111111	000000100000000100001010	2		2			2		2		1		30		30			
H3335	018	0	1	04	01	H3335_018_0	7	4	$0 Copayment	10		000000000000000010000000	2		2			2		2		2							
H3335	038	0	1	04	01	H3335_038_0	7	5	Preventive Services	01	0000000000000000000000000000010000000		2		1	0.00	25.00	2		2		1		30		30			
H3335	038	0	1	04	01	H3335_038_0	7	6	Supplemental Education/Wellness Programs	10		000000000000000010000000	2		2			2		2		2							
H3335	038	0	1	04	01	H3335_038_0	7	7	$25 Copayment	01	0000001100000000000000000000000000000		2		1	25.00	25.00	2		2		2							
H3335	038	0	1	04	01	H3335_038_0	7	4	PT/OT/ST	01	0000000010000010000000000000000000000		2		1	50.00	50.00	2		2		2							
H3335	038	0	1	04	01	H3335_038_0	7	3	$300 Copayment	01	0000000000000000000000001000000000000		2		1	300.00	300.00	2		2		2							
H3335	038	0	1	04	01	H3335_038_0	7	2	50% Coinsurance	01	0000100000000000000000000000000000000		2		2			2		2		1		50		50			
H3335	038	0	1	04	01	H3335_038_0	7	1	30% Coinsurance	11	0000010000100101111011110111101110000	000000100000000100000000	2		2			2		2		1		30		30			
H3335	038	0	1	04	01	H3335_038_0	7	8	$60 Copayment - Specialist Services	11	0111000001011000000100000000000001111	000000000000000000001010	2		1	60.00	60.00	2		2		2							
H3335	041	0	1	04	01	H3335_041_0	7	1	30% Coinsurance	11	0111011111111111111111110111111111111	000000100000000100001010	2		2			2		2		1		30		30			
H3335	041	0	1	04	01	H3335_041_0	7	2	50% Coinsurance	01	0000100000000000000000000000000000000		2		2			2		2		1		50		50			
H3335	041	0	1	04	01	H3335_041_0	7	3	$225 Copayment	01	0000000000000000000000001000000000000		2		1	225.00	225.00	2		2		2							
H3335	041	0	1	04	01	H3335_041_0	7	4	$0 Copayment	10		000000000000000010000000	2		2			2		2		2							
H3335	043	0	1	04	01	H3335_043_0	6	1	30% Coinsurance	11	0111011111111111111111110111111111111	000000100000000100001010	2		2			2		2		1		30		30			
H3335	043	0	1	04	01	H3335_043_0	6	2	50% Coinsurance	01	0000100000000000000000000000000000000		2		2			2		2		1		50		50			
H3335	043	0	1	04	01	H3335_043_0	6	4	$0 Copayment	10		000000000000000010000000	2		2			2		2		2							
H3335	043	0	1	04	01	H3335_043_0	6	3	$225 Copayment	01	0000000000000000000000001000000000000		2		1	225.00	225.00	2		2		2							
H3335	044	0	1	04	01	H3335_044_0	5	1	30% Coinsurance	11	0111011111111111111111110111111111111	000000100000000100001010	2		2			2		2		1		30		30			
H3335	044	0	1	04	01	H3335_044_0	5	3	$225 Copayment	01	0000000000000000000000001000000000000		2		1	225.00	225.00	2		2		2							
H3335	044	0	1	04	01	H3335_044_0	5	2	50% Coinsurance	01	0000100000000000000000000000000000000		2		2			2		2		1		50		50			
H3335	044	0	1	04	01	H3335_044_0	5	4	$0 Copayment	10		000000000000000010000000	2		2			2		2		2							
H3335	051	0	1	04	01	H3335_051_0	7	1	30% Coinsurance	11	0000010000100101111011110111101110000	000000100000000100000000	2		2			2		2		1		30		30			
H3335	051	0	1	04	01	H3335_051_0	7	2	50% Coinsurance	01	0000100000000000000000000000000000000		2		2			2		2		1		50		50			
H3335	051	0	1	04	01	H3335_051_0	7	8	$60 Copayment - Specialist Services	11	0111000001011000000100000000000001111	000000000000000000001010	2		1	60.00	60.00	2		2		2							
H3335	051	0	1	04	01	H3335_051_0	7	7	$25 Copayment	01	0000001100000000000000000000000000000		2		1	25.00	25.00	2		2		2							
H3335	051	0	1	04	01	H3335_051_0	7	6	Supplemental Education/Wellness Programs	10		000000000000000010000000	2		2			2		2		2							
H3335	051	0	1	04	01	H3335_051_0	7	5	Preventive Services	01	0000000000000000000000000000010000000		2		1	0.00	25.00	2		2		1		30		30			
H3335	051	0	1	04	01	H3335_051_0	7	4	PT/OT/ST	01	0000000010000010000000000000000000000		2		1	50.00	50.00	2		2		2							
H3335	051	0	1	04	01	H3335_051_0	7	3	$300 Copayment	01	0000000000000000000000001000000000000		2		1	300.00	300.00	2		2		2							
H3335	052	0	1	04	01	H3335_052_0	6	1	30% Coinsurance	11	0111010100111101111111110111111110010	000000100000000100000000	2		2			2		2		1		30		30			
H3335	052	0	1	04	01	H3335_052_0	6	2	50% Coinsurance	01	0000100000000000000000000000000000000		2		2			2		2		1		50		50			
H3335	052	0	1	04	01	H3335_052_0	6	3	$250 Copayment	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H3335	052	0	1	04	01	H3335_052_0	6	4	$50 Copayment	11	0000000011000010000000000000000001101	000000000000000000001010	2		1	50.00	50.00	2		2		2							
H3335	052	0	1	04	01	H3335_052_0	6	5	Supplemental Education/Wellness Programs	10		000000000000000010000000	2		2			2		2		2							
H3335	052	0	1	04	01	H3335_052_0	6	6	$30 Copayment	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H3335	801	0	1	04	01	H3335_801_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H3335	801	0	1	04	01	H3335_801_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H3335	811	0	1	04	01	H3335_811_0	3	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H3335	811	0	1	04	01	H3335_811_0	3	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H3335	813	0	1	04	01	H3335_813_0	2	2	$0 Copayment	01	0000010000000000000000000000000000000		2		1	0.00	0.00	2		2		2							
H3335	813	0	1	04	01	H3335_813_0	2	3	20% Coinsurance	01	0000100000100100000000100000000000000		2		2			2		2		1		20		20			
H3335	813	0	1	04	01	H3335_813_0	2	1	20% Coinsurance	01	0111001111011011111111011111111111111		2		2			2		2		1		20		20			
H3335	819	0	1	04	01	H3335_819_0	3	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H3335	819	0	1	04	01	H3335_819_0	3	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H3335	820	0	1	04	01	H3335_820_0	3	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H3335	820	0	1	04	01	H3335_820_0	3	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H3335	822	0	1	04	01	H3335_822_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H3335	822	0	1	04	01	H3335_822_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H3342	019	0	1	04	01	H3342_019_0	12	2	$50 Copay	11	0000001000001000000000000000000000000	000000000000000100000000	2		1	50.00	50.00	2		2		2							
H3342	019	0	1	04	01	H3342_019_0	12	9	40% Coinsurance	01	0000000000000000000010000000000000000		2		1	50.00	75.00	2		2		1		40		40			
H3342	019	0	1	04	01	H3342_019_0	12	14	$0 Copay - Vision Exam	10		000000000000000000001000	1	69.00	1	0.00	0.00	2		2		2							
H3342	019	0	1	04	01	H3342_019_0	12	13	40% Coinsurance - Therapuetic	01	0000000000000000001000000000000000000		2		2			2		1	2	1		40		40	1	50.00	75.00
H3342	019	0	1	04	01	H3342_019_0	12	12	40% Coinsurance	01	0000000000000000000001000111000000000		2		2			2		2		1		40		40			
H3342	019	0	1	04	01	H3342_019_0	12	11	30% Coinsurance	01	0000000000000000000000000000000010000		2		2			2		2		1		30		30			
H3342	019	0	1	04	01	H3342_019_0	12	10	20% Coinsurance	11	0000000000000000000000000000100001000	000000000000000000100000	2		2			2		2		1		20		20			
H3342	019	0	1	04	01	H3342_019_0	12	1	$0 Copay	11	0000000000000000000000010000001100110	000000100000000000000000	2		1	0.00	0.00	2		2		2							
H3342	019	0	1	04	01	H3342_019_0	12	3	$75 Copay	01	0111010111010010000000000000000000101		2		1	75.00	75.00	2		2		2							
H3342	019	0	1	04	01	H3342_019_0	12	4	$100 Copay	01	0000100000100100000000100000000000000		2		1	100.00	100.00	2		2		2							
H3342	019	0	1	04	01	H3342_019_0	12	5	$295 Copay	01	0000000000000000000000001000000000000		2		1	295.00	295.00	2		2		2							
H3342	019	0	1	04	01	H3342_019_0	12	6	$55 - $80 Copay	01	0000000000000001100000000000000000000		2		1	55.00	80.00	2		1	2	2					1	50.00	75.00
H3342	019	0	1	04	01	H3342_019_0	12	7	$0 - $100 Copay	01	0000000000000000000000000000010000000		2		1	0.00	100.00	2		2		2							
H3342	019	0	1	04	01	H3342_019_0	12	8	$150 - $200 Copay	01	0000000000000000010100000000000000000		2		1	150.00	200.00	2		1	2	2					1	50.00	75.00
H3342	019	0	1	04	01	H3342_019_0	12	15	$0 - 50% for Web/Phone-Based Technology	10		000000000000000010000000	2		1	0.00	0.00	2		2		1		50		50			
H3342	020	0	1	04	01	H3342_020_0	11	2	$30 Copay	11	0000001000001000000000000000000000000	000000000000000100000000	2		1	30.00	30.00	2		2		2							
H3342	020	0	1	04	01	H3342_020_0	11	15	$0 Copay - Vision Exam	10		000000000000000000001000	1	69.00	1	0.00	0.00	2		2		2							
H3342	020	0	1	04	01	H3342_020_0	11	14	75% Coinsurance - Hearing Aids	10		000000000000000000000001	1	1000.00	2			2		2		1		75		75			
H3342	020	0	1	04	01	H3342_020_0	11	13	75% Coinsurance - Hearing Exam	10		000000000000000000000010	1	50.00	2			2		2		1		75		75			
H3342	020	0	1	04	01	H3342_020_0	11	12	$0 Copay - Eyewear	10		000000000000000000000100	1	80.00	1	0.00	0.00	2		2		2							
H3342	020	0	1	04	01	H3342_020_0	11	11	30% Coinsurance	01	0000000000000000000000000111000010000		2		2			2		2		1		30		30			
H3342	020	0	1	04	01	H3342_020_0	11	10	20% Coinsurance	11	0000000000000000001000000000100001000	000000000000000000100000	2		2			2		2		1		20		20			
H3342	020	0	1	04	01	H3342_020_0	11	1	$0  Copay	11	0000000000000000000000010000001100010	000000100000000000000000	2		1	0.00	0.00	2		2		2							
H3342	020	0	1	04	01	H3342_020_0	11	3	$55 Copay	01	0111010111010010000000000000000000101		2		1	55.00	55.00	2		2		2							
H3342	020	0	1	04	01	H3342_020_0	11	9	25% Coinsurance	01	0000000000000000000011000000000000000		2		1	30.00	55.00	2		2		1		25		25			
H3342	020	0	1	04	01	H3342_020_0	11	8	$125 - $150 Copay	01	0000000000000000010100000000000000000		2		1	125.00	150.00	2		1	2	2					1	30.00	55.00
H3342	020	0	1	04	01	H3342_020_0	11	7	$55 - $75 Copay	01	0000000000000001100000000000000000000		2		1	55.00	75.00	2		1	2	2					1	30.00	55.00
H3342	020	0	1	04	01	H3342_020_0	11	6	$0 - $100 Copay - 50% Coinsurance	11	0000000000000000000000000000010000100	000000000000000010000000	2		1	0.00	100.00	2		2		1		50		50			
H3342	020	0	1	04	01	H3342_020_0	11	5	$275 Copay	01	0000000000000000000000001000000000000		2		1	275.00	275.00	2		2		2							
H3342	020	0	1	04	01	H3342_020_0	11	4	$100 Copay	01	0000100000100100000000100000000000000		2		1	100.00	100.00	2		2		2							
H3342	808	0	1	04	01	H3342_808_0	6	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H3342	808	0	1	04	01	H3342_808_0	6	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H3342	809	0	1	04	01	H3342_809_0	6	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H3342	809	0	1	04	01	H3342_809_0	6	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H3342	810	0	1	04	01	H3342_810_0	6	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H3342	810	0	1	04	01	H3342_810_0	6	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H3344	005	0	1	04	01	H3344_005_0	6	2	$40 copayment	01	0000001001011000000000000000000000100		2		1	40.00	40.00	2		2		2							
H3344	005	0	1	04	01	H3344_005_0	6	1	$0 Copayment	11	0000000000000000000000000000100000010	000000000000000010000000	2		2			2		2		2							
H3344	005	0	1	04	01	H3344_005_0	6	3	$200 copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H3344	005	0	1	04	01	H3344_005_0	6	5	45% coinsurance	01	0000100000100100000000100000000000000		2		2			2		2		1		45		45			
H3344	005	0	1	04	01	H3344_005_0	6	6	50% coinsurance	11	0000000100000000000000000110000000000	000000000000000000100000	2		2			2		2		1		50		50			
H3344	005	0	1	04	01	H3344_005_0	6	4	30%	11	0111010010000011100011010001011111001	000000100000000001001010	2		2			2		2		1		30		30			
H3344	005	0	1	04	01	H3344_005_0	6	8	30% for 8b grouping	01	0000000000000000011100000000000000000		2		2			2		1	2	1		30		30	1	40.00	40.00
H3344	005	0	1	04	01	H3344_005_0	6	7	150 eyewear	10		000000000000000000000100	1	150.00	2			2		2		2							
H3344	801	0	1	04	01	H3344_801_0	4	1	20%	01	0111111111111111111111111111111111111		2		2			2		2		1		20		20			
H3344	803	0	1	04	01	H3344_803_0	2	1	20%	01	0111111111111111111111111111111111111		2		2			2		2		1		20		20			
H3344	804	0	1	04	01	H3344_804_0	2	1	20%	01	0111111111111111111111111111111111111		2		2			2		2		1		20		20			
H3404	001	0	1	04	01	H3404_001_0	10	4	Eye Exam OON	10		000000000000000000001000	1	100.00	2			2		2		1		20		20			
H3404	001	0	1	04	01	H3404_001_0	10	3	20% Coinsurance	11	0111111111111111110111110111100011111	000000100000000000000000	2		2			2		2		1		20		20			
H3404	001	0	1	04	01	H3404_001_0	10	2	$0 Copay	11	0000000000000000001000000000011100000	000000000000000110000000	2		1	0.00	0.00	2		2		2							
H3404	001	0	1	04	01	H3404_001_0	10	1	$100 Copay	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H3404	002	0	1	04	01	H3404_002_0	9	8	$40 copay	01	0111001001011000000000000000000001001		2		1	40.00	40.00	2		2		2							
H3404	002	0	1	04	01	H3404_002_0	9	7	Eye Exam	10		000000000000000000001000	1	100.00	1	35.00	35.00	2		2		2							
H3404	002	0	1	04	01	H3404_002_0	9	6	15% Coinsurance	01	0000000000000001110100000000000000000		2		2			2		2		1		15		15			
H3404	002	0	1	04	01	H3404_002_0	9	5	$125 Copay	01	0000000000000000000011000000000000000		2		1	125.00	125.00	2		2		2							
H3404	002	0	1	04	01	H3404_002_0	9	1	$35 copay	01	0000100110100110000000100000000000100		2		1	35.00	35.00	2		2		2							
H3404	002	0	1	04	01	H3404_002_0	9	2	20% coinsurance	01	0000000000000000000000000111000010010		2		2			2		2		1		20		20			
H3404	002	0	1	04	01	H3404_002_0	9	3	$100 Copay	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H3404	002	0	1	04	01	H3404_002_0	9	4	No Cost Sharing	11	0000010000000000001000010000111100000	000000100000000110000000	2		1	0.00	0.00	2		2		2							
H3404	801	0	1	04	01	H3404_801_0	5	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
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H3421	001	0	1	09	04	H3421_001_0	5	9	15	01	0000000000000001000000000000000000000		2		1	15.00	15.00	2		1	2	2					1	15.00	50.00
H3421	001	0	1	09	04	H3421_001_0	5	8	15	01	0000001000000000000000000000000000000		2		1	15.00	15.00	2		2		2							
H3421	001	0	1	09	04	H3421_001_0	5	7	50-250	01	0111000000000000000011100000000000000		2		1	50.00	250.00	2		2		2							
H3421	001	0	1	09	04	H3421_001_0	5	6	50 medicare	01	0000000000000000000000000000000001111		2		2			2		2		1		50		50			
H3421	001	0	1	09	04	H3421_001_0	5	5	40	01	0000000010100110000000000000000000000		2		1	40.00	40.00	2		2		2							
H3421	001	0	1	09	04	H3421_001_0	5	4	10	01	0000000000000000100000000000000000000		2		1	10.00	10.00	2		1	2	2					1	15.00	50.00
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H3421	001	0	1	09	04	H3421_001_0	5	2	20	01	0000000100000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H3421	001	0	1	09	04	H3421_001_0	5	15	200	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H3421	001	0	1	09	04	H3421_001_0	5	14	50	10		000000000000000010101111	1	500.00	2			2		2		1		50		50			
H3421	001	0	1	09	04	H3421_001_0	5	13	0	11	0000010000000000000000010000011100000	000000100000000000000000	2		2			2		2		2							
H3421	001	0	1	09	04	H3421_001_0	5	12	20	01	0000000000000000011100000000000000000		2		2			2		1	2	1		20		20	1	15.00	50.00
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H3421	001	0	1	09	04	H3421_001_0	5	1	55	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
H3421	001	0	1	09	04	H3421_001_0	5	10	23-24	01	0000000000000000000000000111000000000		2		2			2		2		1		23		24			
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H3421	002	0	1	09	04	H3421_002_0	9	5	50	01	0000000001011000000000000000000000000		2		1	50.00	50.00	2		2		2							
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H3421	002	0	1	09	04	H3421_002_0	9	3	50 med	01	0000000000000000000000000000000001111		2		2			2		2		1		50		50			
H3421	002	0	1	09	04	H3421_002_0	9	2	20	01	0000001100000000000000000000000000000		2		1	20.00	20.00	2		2		2							
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H3421	002	0	1	09	04	H3421_002_0	9	14	50 non med	10		000000000000000010001111	1	500.00	2			2		2		1		50		50			
H3421	002	0	1	09	04	H3421_002_0	9	13	0	11	0000010000000000000000010000011100000	000000100000000000000000	2		2			2		2		2							
H3421	002	0	1	09	04	H3421_002_0	9	12	20	01	0000000000000000011100000000000000000		2		2			2		1	2	1		20		20	1	20.00	50.00
H3421	002	0	1	09	04	H3421_002_0	9	11	20 no	01	0000000000000000000000000000100010000		2		2			2		2		1		20		20			
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H3421	002	0	1	09	04	H3421_002_0	9	1	55	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
H3421	002	0	1	09	04	H3421_002_0	9	7	50-250	01	0111000000000000000011100000000000000		2		1	50.00	250.00	2		2		2							
H3812	001	0	1	04	01	H3812_001_0	4	1	Group 1	01	0000001000000000000000000000000000000		2		1	25.00	25.00	2		2		2							
H3812	001	0	1	04	01	H3812_001_0	4	10	Group 10	11	0000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H3812	001	0	1	04	01	H3812_001_0	4	9	Group 9	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H3812	001	0	1	04	01	H3812_001_0	4	8	Group 8	01	0000000000100100000000100000000000000		2		1	35.00	45.00	2		2		2							
H3812	001	0	1	04	01	H3812_001_0	4	7	Group 7	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H3812	001	0	1	04	01	H3812_001_0	4	6	Group 6	01	0000100000000000000000000000000000000		2		1	75.00	75.00	2		2		2							
H3812	001	0	1	04	01	H3812_001_0	4	5	Group 5	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H3812	001	0	1	04	01	H3812_001_0	4	4	Group 4	01	0000000000000001111100000000000000000		2		1	13.00	21.00	2		1	2	1		30		30	1	25.00	50.00
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H3812	001	0	1	04	01	H3812_001_0	4	12	Group 12	01	0000010000000000000000000100000000000		2		2			2		2		1		50		50			
H3812	001	0	1	04	01	H3812_001_0	4	13	Group 13	01	0000000000001000000000000000000000000		2		1	25.00	50.00	2		2		2							
H3812	001	0	1	04	01	H3812_001_0	4	2	Group 2	11	0111000111010010000000000000000001101	000001000000000000001010	2		1	50.00	50.00	2		2		2							
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H3812	005	0	1	04	01	H3812_005_0	5	2	Group 2	11	0000000000000000000000000000000000010	000000000000000000010001	2		1	0.00	0.00	2		2		2							
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H3812	005	0	1	04	01	H3812_005_0	5	7	Group 7	10		000000000000000000100000	1	1000.00	1	0.00	0.00	2		2		2							
H3812	005	0	1	04	01	H3812_005_0	5	6	Group 6	01	0000000000000001111100000000000000000		2		2			2		1	1	1	30	0	30	30	2		
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H3812	005	0	1	04	01	H3812_005_0	5	4	Group 4	10		000000010000000000000000	2		2			2		2		1		75		75			
H3812	005	0	1	04	01	H3812_005_0	5	8	Group 8	10		000000000000000000000100	1	150.00	1	0.00	0.00	2		2		2							
H3813	001	0	1	04	01	H3813_001_0	5	8	$10.00 copayment	01	0000000000000000000000000001000000000		2		1	10.00	10.00	2		2		1		20		20			
H3813	001	0	1	04	01	H3813_001_0	5	3	20% Coinsurance	01	0000000000000000011100000110100010000		2		2			2		2		1		20		20			
H3813	001	0	1	04	01	H3813_001_0	5	1	$0 Copayment	11	0000010000000001100000010000011100110	000000000000000010000000	2		2			2		2		2							
H3813	001	0	1	04	01	H3813_001_0	5	4	$20 - $30 Copayment	01	0000000000100100000000100000000000000		2		1	20.00	30.00	2		2		2							
H3813	001	0	1	04	01	H3813_001_0	5	5	$20 Copayment	01	0000001100000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H3813	001	0	1	04	01	H3813_001_0	5	6	$100 Copayment	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H3813	001	0	1	04	01	H3813_001_0	5	7	$300 Copayment	01	0000000000000000000011000000000000000		2		1	300.00	300.00	2		2		2							
H3813	001	0	1	04	01	H3813_001_0	5	2	$35 Copayment	11	0111100011011010000000000000000001001	000000000000000000001000	2		1	35.00	35.00	2		2		2							
H3813	004	0	1	04	01	H3813_004_0	7	6	$35.00 copayment	11	0111101011010010000000000000000001001	000000000000000000001000	2		1	35.00	35.00	2		2		2							
H3813	004	0	1	04	01	H3813_004_0	7	7	20% coinsurance	01	0000000000000000011111000110100010000		2		2			2		2		1		20		20			
H3813	004	0	1	04	01	H3813_004_0	7	8	$100 copayment	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H3813	004	0	1	04	01	H3813_004_0	7	4	$20-$30 copayment	01	0000000000100100000000100000000000000		2		1	20.00	30.00	2		2		2							
H3813	004	0	1	04	01	H3813_004_0	7	5	$20 - $35 copayment	01	0000000000001000000000000000000000000		2		1	20.00	35.00	2		2		2							
H3813	004	0	1	04	01	H3813_004_0	7	3	$20.00 copayment	01	0000000100000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H3813	004	0	1	04	01	H3813_004_0	7	2		01	0000000000000000000000000001000000000		2		1	10.00	10.00	2		2		1		20		20			
H3813	004	0	1	04	01	H3813_004_0	7	1	zero copay	11	0000010000000001100000010000011100110	000000000000000010000000	2		1	0.00	0.00	2		2		2							
H3813	005	0	1	04	01	H3813_005_0	7	8	$100 copayment	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H3813	005	0	1	04	01	H3813_005_0	7	2		01	0000000000000000000000000001000000000		2		1	10.00	10.00	2		2		1		20		20			
H3813	005	0	1	04	01	H3813_005_0	7	1	zero copay	11	0000010000000001100000010000011100110	000000000000000010000000	2		1	0.00	0.00	2		2		2							
H3813	005	0	1	04	01	H3813_005_0	7	7	20% coinsurance	01	0000000000000000011111000110100010000		2		2			2		2		1		20		20			
H3813	005	0	1	04	01	H3813_005_0	7	6	$35.00 copayment	11	0111101011010010000000000000000001001	000000000000000000001000	2		1	35.00	35.00	2		2		2							
H3813	005	0	1	04	01	H3813_005_0	7	5	$20 - $35 copayment	01	0000000000001000000000000000000000000		2		1	20.00	35.00	2		2		2							
H3813	005	0	1	04	01	H3813_005_0	7	4	$20-$30 copayment	01	0000000000100100000000100000000000000		2		1	20.00	30.00	2		2		2							
H3813	005	0	1	04	01	H3813_005_0	7	3	$20.00 copayment	01	0000000100000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H3813	006	0	1	04	01	H3813_006_0	8	9	25 % coinsurance	01	0000000000000000000011000000000000000		2		2			2		2		1		25		25			
H3813	006	0	1	04	01	H3813_006_0	8	8	$250 copayment	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H3813	006	0	1	04	01	H3813_006_0	8	7	20% coinsurance	01	0000000000000000011100000110100010000		2		2			2		2		1		20		20			
H3813	006	0	1	04	01	H3813_006_0	8	6	$35.00 copayment	01	0111100010000010000000000000000000000		2		1	35.00	35.00	2		2		2							
H3813	006	0	1	04	01	H3813_006_0	8	5	$20 - $50 copayment	01	0000000000001000000000000000000000000		2		1	20.00	50.00	2		2		2							
H3813	006	0	1	04	01	H3813_006_0	8	4	$20-$30 copayment	01	0000000000100100000000100000000000000		2		1	20.00	30.00	2		2		2							
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H3813	006	0	1	04	01	H3813_006_0	8	11	$25.00 copayment	01	0000001000000000000000000000000000000		2		1	25.00	25.00	2		2		2							
H3813	006	0	1	04	01	H3813_006_0	8	10	$50.00 copayment	01	0000000001010000000000000000000001001		2		1	50.00	50.00	2		2		2							
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H3813	006	0	1	04	01	H3813_006_0	8	3	$20.00 copayment	01	0000000100000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H3813	802	0	1	04	01	H3813_802_0	5	3	$15 - $20 copayment	01	0000000000001000000000000000000000000		2		1	15.00	20.00	2		2		2							
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H3813	802	0	1	04	01	H3813_802_0	5	1	zero copayment	11	0000010000000001100000010000011100110	000000000000000010000000	2		2			2		2		2							
H3813	802	0	1	04	01	H3813_802_0	5	8	diabetic supplies Therapeutic shoes	01	0000000000000000000000000001000000000		2		2			2		2		1		10		10			
H3813	802	0	1	04	01	H3813_802_0	5	5	10% coinsurance	01	0000000000000000011100000110100010000		2		2			2		2		1		10		10			
H3813	802	0	1	04	01	H3813_802_0	5	6	$50 copayment	01	0000000000000000000000001000000000000		2		1	50.00	50.00	2		2		2							
H3813	802	0	1	04	01	H3813_802_0	5	7	$125.00 copayment	01	0000000000000000000011000000000000000		2		1	125.00	125.00	2		2		2							
H3813	802	0	1	04	01	H3813_802_0	5	4	$20.00 copayment	11	0111100111110110000000100000000001001	000000000000000000001000	2		1	20.00	20.00	2		2		2							
H3817	007	1	1	04	01	H3817_007_1	8	1	$25 copay	01	0000001100010000000000000000000000000		2		1	25.00	25.00	2		2		2							
H3817	007	1	1	04	01	H3817_007_1	8	10	10% coinsurance	01	0000000000000000000000000000100000000		2		2			2		2		1		10		10			
H3817	007	1	1	04	01	H3817_007_1	8	11	20% coinsurance	01	0000010000000000000000000000000010000		2		2			2		2		1		20		20			
H3817	007	1	1	04	01	H3817_007_1	8	12	30% coinsurance	01	0000000000000000011100000110000000000		2		2			2		2		1		30		30			
H3817	007	1	1	04	01	H3817_007_1	8	2	$45 copay	01	0111000011101110000000100000000001101		2		1	45.00	45.00	2		2		2							
H3817	007	1	1	04	01	H3817_007_1	8	9	$200 copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H3817	007	1	1	04	01	H3817_007_1	8	4	0 - Zero cost share	11	0000100000000001100000010001011100010	000000100000000110000000	2		2			2		2		2							
H3817	007	1	1	04	01	H3817_007_1	8	5	$0 to $350 copay	01	0000000000000000000010000000000000000		2		1	0.00	350.00	2		2		2							
H3817	007	1	1	04	01	H3817_007_1	8	6	$0 to $250 copay	01	0000000000000000000001000000000000000		2		1	0.00	250.00	2		2		2							
H3817	007	1	1	04	01	H3817_007_1	8	7	$35 copay VSP exam	10		000000000000000000001000	2		1	35.00	35.00	2		2		2							
H3817	007	1	1	04	01	H3817_007_1	8	8	VSP Eyewear $100 Maximum	10		000000000000000000000100	1	100.00	2			2		2		2							
H3817	007	1	1	04	01	H3817_007_1	8	3	Dental Preventive Services $500 maximum	10		000000000000000000100000	1	500.00	2			2		2		1		50		50			
H3817	007	2	1	04	01	H3817_007_2	8	1	$25 copay	01	0000001100010000000000000000000000000		2		1	25.00	25.00	2		2		2							
H3817	007	2	1	04	01	H3817_007_2	8	10	10% coinsurance	01	0000000000000000000000000000100000000		2		2			2		2		1		10		10			
H3817	007	2	1	04	01	H3817_007_2	8	11	20% coinsurance	01	0000010000000000000000000000000010000		2		2			2		2		1		20		20			
H3817	007	2	1	04	01	H3817_007_2	8	12	30% coinsurance	01	0000000000000000011100000110000000000		2		2			2		2		1		30		30			
H3817	007	2	1	04	01	H3817_007_2	8	2	$45 copay	01	0111000011101110000000100000000001101		2		1	45.00	45.00	2		2		2							
H3817	007	2	1	04	01	H3817_007_2	8	3	Dental Preventive Services $500 maximum	10		000000000000000000100000	1	500.00	2			2		2		1		50		50			
H3817	007	2	1	04	01	H3817_007_2	8	4	0 - Zero cost share	11	0000100000000001100000010001011100010	000000100000000110000000	2		2			2		2		2							
H3817	007	2	1	04	01	H3817_007_2	8	5	$0 to $350 copay	01	0000000000000000000010000000000000000		2		1	0.00	350.00	2		2		2							
H3817	007	2	1	04	01	H3817_007_2	8	6	$0 to $250 copay	01	0000000000000000000001000000000000000		2		1	0.00	250.00	2		2		2							
H3817	007	2	1	04	01	H3817_007_2	8	7	$35 copay VSP exam	10		000000000000000000001000	2		1	35.00	35.00	2		2		2							
H3817	007	2	1	04	01	H3817_007_2	8	8	VSP Eyewear $100 Maximum	10		000000000000000000000100	1	100.00	2			2		2		2							
H3817	007	2	1	04	01	H3817_007_2	8	9	$200 copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H3817	007	3	1	04	01	H3817_007_3	8	1	$25 copay	01	0000001100010000000000000000000000000		2		1	25.00	25.00	2		2		2							
H3817	007	3	1	04	01	H3817_007_3	8	10	10% coinsurance	01	0000000000000000000000000000100000000		2		2			2		2		1		10		10			
H3817	007	3	1	04	01	H3817_007_3	8	11	20% coinsurance	01	0000010000000000000000000000000010000		2		2			2		2		1		20		20			
H3817	007	3	1	04	01	H3817_007_3	8	12	30% coinsurance	01	0000000000000000011100000110000000000		2		2			2		2		1		30		30			
H3817	007	3	1	04	01	H3817_007_3	8	2	$45 copay	01	0111000011101110000000100000000001101		2		1	45.00	45.00	2		2		2							
H3817	007	3	1	04	01	H3817_007_3	8	9	$200 copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H3817	007	3	1	04	01	H3817_007_3	8	4	0 - Zero cost share	11	0000100000000001100000010001011100010	000000100000000110000000	2		2			2		2		2							
H3817	007	3	1	04	01	H3817_007_3	8	5	$0 to $350 copay	01	0000000000000000000010000000000000000		2		1	0.00	350.00	2		2		2							
H3817	007	3	1	04	01	H3817_007_3	8	6	$0 to $250 copay	01	0000000000000000000001000000000000000		2		1	0.00	250.00	2		2		2							
H3817	007	3	1	04	01	H3817_007_3	8	7	$35 copay VSP exam	10		000000000000000000001000	2		1	35.00	35.00	2		2		2							
H3817	007	3	1	04	01	H3817_007_3	8	8	VSP Eyewear $100 Maximum	10		000000000000000000000100	1	100.00	2			2		2		2							
H3817	007	3	1	04	01	H3817_007_3	8	3	Dental Preventive Services $500 maximum	10		000000000000000000100000	1	500.00	2			2		2		1		50		50			
H3817	008	1	1	04	01	H3817_008_1	9	2	$45 copay	01	0111000011101110000000100000000001101		2		1	45.00	45.00	2		2		2							
H3817	008	1	1	04	01	H3817_008_1	9	12	30% coinsurance	01	0000000000000000011100000110000000000		2		2			2		2		1		30		30			
H3817	008	1	1	04	01	H3817_008_1	9	11	20% coinsurance	11	0000010000000000000000000000000010000	000000000000000001000000	2		2			2		2		1		20		20			
H3817	008	1	1	04	01	H3817_008_1	9	10	10% coinsurance	01	0000000000000000000000000000100000000		2		2			2		2		1		10		10			
H3817	008	1	1	04	01	H3817_008_1	9	1	$25 copay	01	0000001100010000000000000000000000000		2		1	25.00	25.00	2		2		2							
H3817	008	1	1	04	01	H3817_008_1	9	9	$200 copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H3817	008	1	1	04	01	H3817_008_1	9	4	0 - Zero cost share	11	0000100000000001100000010001011100010	000000100000000110000000	2		2			2		2		2							
H3817	008	1	1	04	01	H3817_008_1	9	5	$0 to $350 copay	01	0000000000000000000010000000000000000		2		1	0.00	350.00	2		2		2							
H3817	008	1	1	04	01	H3817_008_1	9	6	$0 to $250 copay	01	0000000000000000000001000000000000000		2		1	0.00	250.00	2		2		2							
H3817	008	1	1	04	01	H3817_008_1	9	7	$35 copay VSP exam	10		000000000000000000001000	2		1	35.00	35.00	2		2		2							
H3817	008	1	1	04	01	H3817_008_1	9	8	VSP Eyewear $100 Maximum	10		000000000000000000000100	1	100.00	2			2		2		2							
H3817	008	1	1	04	01	H3817_008_1	9	3	Dental Preventive Services $500 maximum	10		000000000000000000100000	1	500.00	2			2		2		1		50		50			
H3817	008	2	1	04	01	H3817_008_2	9	2	$45 copay	01	0111000011101110000000100000000001101		2		1	45.00	45.00	2		2		2							
H3817	008	2	1	04	01	H3817_008_2	9	12	30% coinsurance	01	0000000000000000011100000110000000000		2		2			2		2		1		30		30			
H3817	008	2	1	04	01	H3817_008_2	9	11	20% coinsurance	11	0000010000000000000000000000000010000	000000000000000001000000	2		2			2		2		1		20		20			
H3817	008	2	1	04	01	H3817_008_2	9	10	10% coinsurance	01	0000000000000000000000000000100000000		2		2			2		2		1		10		10			
H3817	008	2	1	04	01	H3817_008_2	9	1	$25 copay	01	0000001100010000000000000000000000000		2		1	25.00	25.00	2		2		2							
H3817	008	2	1	04	01	H3817_008_2	9	3	Dental Preventive Services $500 maximum	10		000000000000000000100000	1	500.00	2			2		2		1		50		50			
H3817	008	2	1	04	01	H3817_008_2	9	9	$200 copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H3817	008	2	1	04	01	H3817_008_2	9	8	VSP Eyewear $100 Maximum	10		000000000000000000000100	1	100.00	2			2		2		2							
H3817	008	2	1	04	01	H3817_008_2	9	7	$35 copay VSP exam	10		000000000000000000001000	2		1	35.00	35.00	2		2		2							
H3817	008	2	1	04	01	H3817_008_2	9	6	$0 to $250 copay	01	0000000000000000000001000000000000000		2		1	0.00	250.00	2		2		2							
H3817	008	2	1	04	01	H3817_008_2	9	5	$0 to $350 copay	01	0000000000000000000010000000000000000		2		1	0.00	350.00	2		2		2							
H3817	008	2	1	04	01	H3817_008_2	9	4	0 - Zero cost share	11	0000100000000001100000010001011100010	000000100000000110000000	2		2			2		2		2							
H3817	008	3	1	04	01	H3817_008_3	9	1	$25 copay	01	0000001100010000000000000000000000000		2		1	25.00	25.00	2		2		2							
H3817	008	3	1	04	01	H3817_008_3	9	10	10% coinsurance	01	0000000000000000000000000000100000000		2		2			2		2		1		10		10			
H3817	008	3	1	04	01	H3817_008_3	9	11	20% coinsurance	11	0000010000000000000000000000000010000	000000000000000001000000	2		2			2		2		1		20		20			
H3817	008	3	1	04	01	H3817_008_3	9	12	30% coinsurance	01	0000000000000000011100000110000000000		2		2			2		2		1		30		30			
H3817	008	3	1	04	01	H3817_008_3	9	2	$45 copay	01	0111000011101110000000100000000001101		2		1	45.00	45.00	2		2		2							
H3817	008	3	1	04	01	H3817_008_3	9	9	$200 copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H3817	008	3	1	04	01	H3817_008_3	9	7	$35 copay VSP exam	10		000000000000000000001000	2		1	35.00	35.00	2		2		2							
H3817	008	3	1	04	01	H3817_008_3	9	6	$0 to $250 copay	01	0000000000000000000001000000000000000		2		1	0.00	250.00	2		2		2							
H3817	008	3	1	04	01	H3817_008_3	9	5	$0 to $350 copay	01	0000000000000000000010000000000000000		2		1	0.00	350.00	2		2		2							
H3817	008	3	1	04	01	H3817_008_3	9	4	0 - Zero cost share	11	0000100000000001100000010001011100010	000000100000000110000000	2		2			2		2		2							
H3817	008	3	1	04	01	H3817_008_3	9	3	Dental Preventive Services $500 maximum	10		000000000000000000100000	1	500.00	2			2		2		1		50		50			
H3817	008	3	1	04	01	H3817_008_3	9	8	VSP Eyewear $100 Maximum	10		000000000000000000000100	1	100.00	2			2		2		2							
H3817	009	1	1	04	01	H3817_009_1	9	1	$20 copay	01	0000001100010000000000000000000000000		2		1	20.00	20.00	2		2		2							
H3817	009	1	1	04	01	H3817_009_1	9	10	10% coinsurance	11	0000010000000000000100000000100010000	000000000000000001000000	2		2			2		2		1		10		10			
H3817	009	1	1	04	01	H3817_009_1	9	9	$200 copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H3817	009	1	1	04	01	H3817_009_1	9	8	VSP Eyewear $200 Maximum	10		000000000000000000000100	1	200.00	2			2		2		2							
H3817	009	1	1	04	01	H3817_009_1	9	7	$25 copay VSP exam	10		000000000000000000001000	2		1	25.00	25.00	2		2		2							
H3817	009	1	1	04	01	H3817_009_1	9	6	$0 to $125copay	01	0000000000000000000001000000000000000		2		1	0.00	125.00	2		2		2							
H3817	009	1	1	04	01	H3817_009_1	9	5	$0 to $300 copay	01	0000000000000000000010000000000000000		2		1	0.00	300.00	2		2		2							
H3817	009	1	1	04	01	H3817_009_1	9	4	0 - Zero cost share	11	0000100000000001100000010001011100010	000000100000000110000000	2		2			2		2		2							
H3817	009	1	1	04	01	H3817_009_1	9	3	Dental Preventive Services $500 maximum	10		000000000000000000100000	1	500.00	2			2		2		1		50		50			
H3817	009	1	1	04	01	H3817_009_1	9	2	$35 copay	01	0111000011101110000000100000000001101		2		1	35.00	35.00	2		2		2							
H3817	009	1	1	04	01	H3817_009_1	9	12	Hearing Aid - $500 maximum	10		000000000000000000000001	1	500.00	2			2		2		2							
H3817	009	1	1	04	01	H3817_009_1	9	11	20% coinsurance	01	0000000000000000011000000110000000000		2		2			2		2		1		20		20			
H3817	009	2	1	04	01	H3817_009_2	9	1	$20 copay	01	0000001100010000000000000000000000000		2		1	20.00	20.00	2		2		2							
H3817	009	2	1	04	01	H3817_009_2	9	8	VSP Eyewear $200 Maximum	10		000000000000000000000100	1	200.00	2			2		2		2							
H3817	009	2	1	04	01	H3817_009_2	9	7	$25 copay VSP exam	10		000000000000000000001000	2		1	25.00	25.00	2		2		2							
H3817	009	2	1	04	01	H3817_009_2	9	6	$0 to $125copay	01	0000000000000000000001000000000000000		2		1	0.00	125.00	2		2		2							
H3817	009	2	1	04	01	H3817_009_2	9	5	$0 to $300 copay	01	0000000000000000000010000000000000000		2		1	0.00	300.00	2		2		2							
H3817	009	2	1	04	01	H3817_009_2	9	9	$200 copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H3817	009	2	1	04	01	H3817_009_2	9	3	Dental Preventive Services $500 maximum	10		000000000000000000100000	1	500.00	2			2		2		1		50		50			
H3817	009	2	1	04	01	H3817_009_2	9	2	$35 copay	01	0111000011101110000000100000000001101		2		1	35.00	35.00	2		2		2							
H3817	009	2	1	04	01	H3817_009_2	9	12	Hearing Aid - $500 maximum	10		000000000000000000000001	1	500.00	2			2		2		2							
H3817	009	2	1	04	01	H3817_009_2	9	11	20% coinsurance	01	0000000000000000011000000110000000000		2		2			2		2		1		20		20			
H3817	009	2	1	04	01	H3817_009_2	9	10	10% coinsurance	11	0000010000000000000100000000100010000	000000000000000001000000	2		2			2		2		1		10		10			
H3817	009	2	1	04	01	H3817_009_2	9	4	0 - Zero cost share	11	0000100000000001100000010001011100010	000000100000000110000000	2		2			2		2		2							
H3817	009	3	1	04	01	H3817_009_3	9	1	$20 copay	01	0000001100010000000000000000000000000		2		1	20.00	20.00	2		2		2							
H3817	009	3	1	04	01	H3817_009_3	9	10	10% coinsurance	11	0000010000000000000100000000100010000	000000000000000001000000	2		2			2		2		1		10		10			
H3817	009	3	1	04	01	H3817_009_3	9	11	20% coinsurance	01	0000000000000000011000000110000000000		2		2			2		2		1		20		20			
H3817	009	3	1	04	01	H3817_009_3	9	12	Hearing Aid - $500 maximum	10		000000000000000000000001	1	500.00	2			2		2		2							
H3817	009	3	1	04	01	H3817_009_3	9	2	$35 copay	01	0111000011101110000000100000000001101		2		1	35.00	35.00	2		2		2							
H3817	009	3	1	04	01	H3817_009_3	9	3	Dental Preventive Services $500 maximum	10		000000000000000000100000	1	500.00	2			2		2		1		50		50			
H3817	009	3	1	04	01	H3817_009_3	9	4	0 - Zero cost share	11	0000100000000001100000010001011100010	000000100000000110000000	2		2			2		2		2							
H3817	009	3	1	04	01	H3817_009_3	9	5	$0 to $300 copay	01	0000000000000000000010000000000000000		2		1	0.00	300.00	2		2		2							
H3817	009	3	1	04	01	H3817_009_3	9	6	$0 to $125copay	01	0000000000000000000001000000000000000		2		1	0.00	125.00	2		2		2							
H3817	009	3	1	04	01	H3817_009_3	9	7	$25 copay VSP exam	10		000000000000000000001000	2		1	25.00	25.00	2		2		2							
H3817	009	3	1	04	01	H3817_009_3	9	8	VSP Eyewear $200 Maximum	10		000000000000000000000100	1	200.00	2			2		2		2							
H3817	009	3	1	04	01	H3817_009_3	9	9	$200 copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H3817	801	0	1	04	01	H3817_801_0	8	2	20% coinsurance	01	0111101111111111011111111111101111111		2		2			2		2		1		20		20			
H3817	801	0	1	04	01	H3817_801_0	8	1	$0 copay	01	0000010000000000100000000000010000000		2		2			2		2		2							
H3817	802	0	1	04	01	H3817_802_0	8	1	$0 copay	01	0000010000000000100000000000010000000		2		2			2		2		2							
H3817	802	0	1	04	01	H3817_802_0	8	2	20% coinsurance	01	0111101111111111011111111111101111111		2		2			2		2		1		20		20			
H3832	007	0	1	04	01	H3832_007_0	10	3	Group 3 - $200	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H3832	007	0	1	04	01	H3832_007_0	10	2	Group 2 - $0	11	0000000000000000000000010000011100010	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H3832	007	0	1	04	01	H3832_007_0	10	1	Group 1 - 30%	01	0111111111111111111111100111100011101		2		2			2		2		1		30		30			
H3832	008	0	1	04	01	H3832_008_0	8	2	Group 2 - $0	11	0000000000000000000000010000011100010	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H3832	008	0	1	04	01	H3832_008_0	8	3	Group 3 - $200	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H3832	008	0	1	04	01	H3832_008_0	8	4	Group 4 - $0, $100 max	10		000000000000000000000100	1	100.00	2			2		2		2							
H3832	008	0	1	04	01	H3832_008_0	8	1	Group 1 - 30%	11	0111111111111111111111100111100011101	000000000000000000001000	2		2			2		2		1		30		30			
H3832	009	0	1	04	01	H3832_009_0	9	4	Group 4 - $0, $100 max	10		000000000000000000000100	1	100.00	2			2		2		2							
H3832	009	0	1	04	01	H3832_009_0	9	3	Group 3 - $200	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H3832	009	0	1	04	01	H3832_009_0	9	2	Group 2 - $0	11	0000000000000000000000010000011100010	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H3832	009	0	1	04	01	H3832_009_0	9	1	Group 1 - 30%	11	0111111111111111111111100111100011101	000000000000000000001000	2		2			2		2		1		30		30			
H3832	010	0	1	04	01	H3832_010_0	7	3	Group 3 - $200	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H3832	010	0	1	04	01	H3832_010_0	7	1	Group 1 - 30%	11	0111111111111111111111100111100011101	000000000000000000001000	2		2			2		2		1		30		30			
H3832	010	0	1	04	01	H3832_010_0	7	2	Group 2 - $0	11	0000000000000000000000010000011100010	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H3832	010	0	1	04	01	H3832_010_0	7	4	Group 4 - $0, $100 max	10		000000000000000000000100	1	100.00	2			2		2		2							
H3832	801	0	1	04	01	H3832_801_0	3	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H3832	801	0	1	04	01	H3832_801_0	3	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H3832	802	0	1	04	01	H3832_802_0	3	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H3832	802	0	1	04	01	H3832_802_0	3	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H3832	805	0	1	04	01	H3832_805_0	3	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H3832	805	0	1	04	01	H3832_805_0	3	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H3832	807	0	1	04	01	H3832_807_0	3	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H3832	807	0	1	04	01	H3832_807_0	3	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H3909	001	0	1	04	01	H3909_001_0	5	4	OON Supplemental Benefits	10		000000000000000010000000	2		2			2		2		2							
H3909	001	0	1	04	01	H3909_001_0	5	3	OON Ambulance	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H3909	001	0	1	04	01	H3909_001_0	5	2	30% possible addl cost-sharing	11	0000000000000001100000000000000100000	000000000000000100000000	2		2			2		1	1	1	30	30	30	30	2		
H3909	001	0	1	04	01	H3909_001_0	5	1	30% OON	11	0111111111111110011111110111011011111	000000100000000000000000	2		2			2		2		1		30		30			
H3909	001	0	1	04	01	H3909_001_0	5	5	Out of Area Dialysis	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H3909	007	0	1	04	01	H3909_007_0	2	4	OON Supplemental Benefits	10		000000000000000010000000	2		2			2		2		2							
H3909	007	0	1	04	01	H3909_007_0	2	3	OON Ambulance	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H3909	007	0	1	04	01	H3909_007_0	2	2	30% possible addl cost-sharing	11	0000000000000001100000000000000100000	000000000000000100000000	2		2			2		1	1	1	30	30	30	30	2		
H3909	007	0	1	04	01	H3909_007_0	2	1	30% OON	11	0111111111111110011111110111011011111	000000100000000000000000	2		2			2		2		1		30		30			
H3909	007	0	1	04	01	H3909_007_0	2	5	Out of Area Dialysis	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H3909	009	0	1	04	01	H3909_009_0	4	1	30% OON	11	0111111111111110011111110111011011111	000000100000000000000000	2		2			2		2		1		30		30			
H3909	009	0	1	04	01	H3909_009_0	4	2	30% possible addl cost-sharing	11	0000000000000001100000000000000100000	000000000000000100000000	2		2			2		1	1	1	30	30	30	30	2		
H3909	009	0	1	04	01	H3909_009_0	4	3	OON Ambulance	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H3909	009	0	1	04	01	H3909_009_0	4	4	OON Supplemental Benefits	10		000000000000000010000000	2		2			2		2		2							
H3909	009	0	1	04	01	H3909_009_0	4	5	Out of Area Dialysis	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H3909	801	0	1	04	01	H3909_801_0	3	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H3909	801	0	1	04	01	H3909_801_0	3	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H3909	802	0	1	04	01	H3909_802_0	6	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H3909	802	0	1	04	01	H3909_802_0	6	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H3912	001	0	1	04	01	H3912_001_0	5	5	Group 5	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H3912	001	0	1	04	01	H3912_001_0	5	4	Group 4	10		000000010000000000000000	2		2			2		2		1		75		75			
H3912	001	0	1	04	01	H3912_001_0	5	3	Group 3	01	0000000000000000000000001000100000000		2		2			2		2		1		20		20			
H3912	001	0	1	04	01	H3912_001_0	5	2	Group 2	11	0000000000000000000000000000000000010	000000000000000000010000	2		1	0.00	0.00	2		2		2							
H3912	001	0	1	04	01	H3912_001_0	5	6	Group 6	01	0000000000000001111100000000000000000		2		2			2		1	1	1	30	0	30	30	2		
H3912	001	0	1	04	01	H3912_001_0	5	1	Group 1	11	0111111111111110000011110111001111101	000001100000000000001010	2		2			2		2		1		30		30			
H3912	001	0	1	04	01	H3912_001_0	5	9	Group 9	10		000000000000000000000100	1	200.00	1	0.00	0.00	2		2		2							
H3912	001	0	1	04	01	H3912_001_0	5	8	Group 8	10		000000000000000000100000	1	250.00	1	0.00	0.00	2		2		2							
H3912	001	0	1	04	01	H3912_001_0	5	7	Group 7	10		000000000100000000000000	1	45.00	1	0.00	0.00	2		2		2							
H3912	001	0	1	04	01	H3912_001_0	5	10	Group 10	10		000000000000000000000001	1	1400.00	1	0.00	0.00	2		2		2							
H3916	001	0	1	04	01	H3916_001_0	9	3	Coinsurance	11	0111110110111110000011110111000001011	000011100000000000000010	2		2			2		2		1		30		30			
H3916	001	0	1	04	01	H3916_001_0	9	2	Preventive Services	01	0000000000000000000000000000011000000		2		2			2		2		2							
H3916	001	0	1	04	01	H3916_001_0	9	12	Diabetes Self Management Training	01	0000000000000000000000000000000100000		2		2			2		1	2	2					1	30.00	40.00
H3916	001	0	1	04	01	H3916_001_0	9	11	Hearing Aids	10		000000000000000000000001	1	500.00	2			2		2		2							
H3916	001	0	1	04	01	H3916_001_0	9	10	Non Medicare Eyewear	10		000000000000000000000100	1	200.00	2			2		2		2							
H3916	001	0	1	04	01	H3916_001_0	9	1	Copay and Coinsurance	11	0000000000000001111100000000000000100	000000000000000000001000	2		2			2		1	2	1		30		30	1	30.00	40.00
H3916	001	0	1	04	01	H3916_001_0	9	9	End Stage Renal and Part B Drugs	01	0000000000000000000000000000100010000		2		2			2		2		1		0		30			
H3916	001	0	1	04	01	H3916_001_0	9	5	Transportation and Preventive Dental	10		000000010000000000100000	2		2			2		2		1		50		50			
H3916	001	0	1	04	01	H3916_001_0	9	6	Fitness Benefit	10		000000000000000010000000	2		2			1	500.00	2		1		50		50			
H3916	001	0	1	04	01	H3916_001_0	9	4	Ambulance	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		1		30		30			
H3916	001	0	1	04	01	H3916_001_0	9	8	Specialist Physician	01	0000000001000000000000000000000000000		2		1	40.00	40.00	2		2		2							
H3916	001	0	1	04	01	H3916_001_0	9	7	Primary Care Physician	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H3916	002	0	1	04	01	H3916_002_0	9	9	End Stage Renal and Part B Drugs	01	0000000000000000000000000000100010000		2		2			2		2		1		0		30			
H3916	002	0	1	04	01	H3916_002_0	9	8	Specialist Physician	01	0000000001000000000000000000000000000		2		1	40.00	40.00	2		2		2							
H3916	002	0	1	04	01	H3916_002_0	9	7	Primary Care Physician	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H3916	002	0	1	04	01	H3916_002_0	9	5	Transportation and Preventive Dental	10		000000010000000000100000	2		2			2		2		1		50		50			
H3916	002	0	1	04	01	H3916_002_0	9	6	Fitness Benefit	10		000000000000000010000000	2		2			1	500.00	2		1		50		50			
H3916	002	0	1	04	01	H3916_002_0	9	4	Ambulance	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		1		30		30			
H3916	002	0	1	04	01	H3916_002_0	9	3	Coinsurance	11	0111110110111110000011110111000001011	000011100000000000000010	2		2			2		2		1		30		30			
H3916	002	0	1	04	01	H3916_002_0	9	2	Preventive Services	01	0000000000000000000000000000011000000		2		2			2		2		2							
H3916	002	0	1	04	01	H3916_002_0	9	12	Diabetes Self Management Training	01	0000000000000000000000000000000100000		2		2			2		1	2	2					1	30.00	40.00
H3916	002	0	1	04	01	H3916_002_0	9	11	Hearing Aids	10		000000000000000000000001	1	500.00	2			2		2		2							
H3916	002	0	1	04	01	H3916_002_0	9	10	Non Medicare Eyewear	10		000000000000000000000100	1	200.00	2			2		2		2							
H3916	002	0	1	04	01	H3916_002_0	9	1	Copay and Coinsurance	11	0000000000000001111100000000000000100	000000000000000000001000	2		2			2		1	2	1		30		30	1	30.00	40.00
H3916	005	0	1	04	01	H3916_005_0	9	1	Copay and Coinsurance	11	0000000000000001111100000000000000100	000000000000000000001000	2		2			2		1	2	1		30		30	1	30.00	40.00
H3916	005	0	1	04	01	H3916_005_0	9	10	Non Medicare Eyewear	10		000000000000000000000100	1	200.00	2			2		2		2							
H3916	005	0	1	04	01	H3916_005_0	9	9	End Stage Renal and Part B Drugs	01	0000000000000000000000000000100010000		2		2			2		2		1		0		30			
H3916	005	0	1	04	01	H3916_005_0	9	8	Specialist Physician	01	0000000001000000000000000000000000000		2		1	40.00	40.00	2		2		2							
H3916	005	0	1	04	01	H3916_005_0	9	7	Primary Care Physician	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H3916	005	0	1	04	01	H3916_005_0	9	6	Fitness Benefit	10		000000000000000010000000	2		2			1	500.00	2		1		50		50			
H3916	005	0	1	04	01	H3916_005_0	9	5	Transportation and Preventive Dental	10		000000010000000000100000	2		2			2		2		1		50		50			
H3916	005	0	1	04	01	H3916_005_0	9	4	Ambulance	01	0000000000000000000000001000000000000		2		1	75.00	75.00	2		2		1		30		30			
H3916	005	0	1	04	01	H3916_005_0	9	3	Coinsurance	11	0111110110111110000011110111000001011	000011100000000000000010	2		2			2		2		1		30		30			
H3916	005	0	1	04	01	H3916_005_0	9	2	Preventive Services	01	0000000000000000000000000000011000000		2		2			2		2		2							
H3916	005	0	1	04	01	H3916_005_0	9	12	Diabetes Self Management Training	01	0000000000000000000000000000000100000		2		2			2		1	2	2					1	30.00	40.00
H3916	005	0	1	04	01	H3916_005_0	9	11	Hearing Aids	10		000000000000000000000001	1	1000.00	2			2		2		2							
H3916	012	0	1	04	01	H3916_012_0	8	1	Copay and Coinsurance	11	0000000000000001111100000000000000100	000000000000000000001000	2		2			2		1	2	1		30		30	1	30.00	45.00
H3916	012	0	1	04	01	H3916_012_0	8	2	Preventive Services	01	0000000000000000000000000000011000000		2		2			2		2		2							
H3916	012	0	1	04	01	H3916_012_0	8	3	Coinsurance	11	0111110110111110000011110111000001011	000011100000000000000010	2		2			2		2		1		30		30			
H3916	012	0	1	04	01	H3916_012_0	8	4	Ambulance	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		1		30		30			
H3916	012	0	1	04	01	H3916_012_0	8	5	Transportation and Preventive Dental	10		000000010000000000100000	2		2			2		2		1		50		50			
H3916	012	0	1	04	01	H3916_012_0	8	9	End Stage Renal and Part B Drugs	01	0000000000000000000000000000100010000		2		2			2		2		1		0		30			
H3916	012	0	1	04	01	H3916_012_0	8	7	Primary Care Physician	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H3916	012	0	1	04	01	H3916_012_0	8	8	Specialist Physician	01	0000000001000000000000000000000000000		2		1	45.00	45.00	2		2		2							
H3916	012	0	1	04	01	H3916_012_0	8	12	Diabetes Self Management Training	01	0000000000000000000000000000000100000		2		2			2		1	2	2					1	30.00	45.00
H3916	012	0	1	04	01	H3916_012_0	8	11	Hearing Aids	10		000000000000000000000001	1	500.00	2			2		2		2							
H3916	012	0	1	04	01	H3916_012_0	8	10	Non Medicare Eyewear	10		000000000000000000000100	1	200.00	2			2		2		2							
H3916	012	0	1	04	01	H3916_012_0	8	6	Fitness Benefit	10		000000000000000010000000	2		2			1	500.00	2		1		50		50			
H3916	015	0	1	04	01	H3916_015_0	10	4	Ambulance	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		1		30		30			
H3916	015	0	1	04	01	H3916_015_0	10	5	Transportation and Preventive Dental	10		000000010000000000100000	2		2			2		2		1		50		50			
H3916	015	0	1	04	01	H3916_015_0	10	6	Fitness Benefit	10		000000000000000010000000	2		2			1	500.00	2		1		50		50			
H3916	015	0	1	04	01	H3916_015_0	10	7	Primary Care Physician	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H3916	015	0	1	04	01	H3916_015_0	10	8	Specialist Physician	01	0000000001000000000000000000000000000		2		1	45.00	45.00	2		2		2							
H3916	015	0	1	04	01	H3916_015_0	10	9	End Stage Renal and Part B Drugs	01	0000000000000000000000000000100010000		2		2			2		2		1		0		30			
H3916	015	0	1	04	01	H3916_015_0	10	1	Copay and Coinsurance	11	0000000000000001111100000000000000100	000000000000000000001000	2		2			2		1	2	1		30		30	1	30.00	45.00
H3916	015	0	1	04	01	H3916_015_0	10	10	Non Medicare Eyewear	10		000000000000000000000100	1	200.00	2			2		2		2							
H3916	015	0	1	04	01	H3916_015_0	10	11	Hearing Aids	10		000000000000000000000001	1	500.00	2			2		2		2							
H3916	015	0	1	04	01	H3916_015_0	10	12	Diabetes Self Management Training	01	0000000000000000000000000000000100000		2		2			2		1	2	2					1	30.00	45.00
H3916	015	0	1	04	01	H3916_015_0	10	2	Preventive Services	01	0000000000000000000000000000011000000		2		2			2		2		2							
H3916	015	0	1	04	01	H3916_015_0	10	3	Coinsurance	11	0111110110111110000011110111000001011	000011100000000000000010	2		2			2		2		1		30		30			
H3916	018	0	1	04	01	H3916_018_0	10	1	Copay and Coinsurance	11	0000000000000001111100000000000000100	000000000000000000001000	2		2			2		1	2	1		30		30	1	30.00	50.00
H3916	018	0	1	04	01	H3916_018_0	10	10	Non Medicare Eyewear	10		000000000000000000000100	1	200.00	2			2		2		2							
H3916	018	0	1	04	01	H3916_018_0	10	11	Hearing Aids	10		000000000000000000000001	1	500.00	2			2		2		2							
H3916	018	0	1	04	01	H3916_018_0	10	12	Diabetes Self Management Training	01	0000000000000000000000000000000100000		2		2			2		1	2	2					1	30.00	50.00
H3916	018	0	1	04	01	H3916_018_0	10	2	Preventive Services	01	0000000000000000000000000000011000000		2		2			2		2		2							
H3916	018	0	1	04	01	H3916_018_0	10	3	Coinsurance	11	0111110110111110000011110111000001011	000011100000000000000010	2		2			2		2		1		30		30			
H3916	018	0	1	04	01	H3916_018_0	10	4	Ambulance	01	0000000000000000000000001000000000000		2		1	125.00	125.00	2		2		1		30		30			
H3916	018	0	1	04	01	H3916_018_0	10	5	Transportation and Preventive Dental	10		000000010000000000100000	2		2			2		2		1		50		50			
H3916	018	0	1	04	01	H3916_018_0	10	6	Fitness Benefit	10		000000000000000010000000	2		2			1	500.00	2		1		50		50			
H3916	018	0	1	04	01	H3916_018_0	10	7	Primary Care Physician	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H3916	018	0	1	04	01	H3916_018_0	10	8	Specialist Physician	01	0000000001000000000000000000000000000		2		1	50.00	50.00	2		2		2							
H3916	018	0	1	04	01	H3916_018_0	10	9	End Stage Renal and Part B Drugs	01	0000000000000000000000000000100010000		2		2			2		2		1		0		30			
H3916	022	0	1	04	01	H3916_022_0	9	3	Coinsurance	11	0111110110111110000011110111000001011	000011100000000000000010	2		2			2		2		1		30		30			
H3916	022	0	1	04	01	H3916_022_0	9	2	Preventive Services	01	0000000000000000000000000000011000000		2		2			2		2		2							
H3916	022	0	1	04	01	H3916_022_0	9	9	End Stage Renal and Part B Drugs	01	0000000000000000000000000000100010000		2		2			2		2		1		0		30			
H3916	022	0	1	04	01	H3916_022_0	9	8	Specialist Physician	01	0000000001000000000000000000000000000		2		1	45.00	45.00	2		2		2							
H3916	022	0	1	04	01	H3916_022_0	9	7	Primary Care Physician	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H3916	022	0	1	04	01	H3916_022_0	9	6	Fitness Benefit	10		000000000000000010000000	2		2			1	500.00	2		1		50		50			
H3916	022	0	1	04	01	H3916_022_0	9	5	Transportation and Preventive Dental	10		000000010000000000100000	2		2			2		2		1		50		50			
H3916	022	0	1	04	01	H3916_022_0	9	4	Ambulance	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		1		30		30			
H3916	022	0	1	04	01	H3916_022_0	9	1	Copay and Coinsurance	11	0000000000000001111100000000000000100	000000000000000000001000	2		2			2		1	2	1		30		30	1	30.00	45.00
H3916	022	0	1	04	01	H3916_022_0	9	10	Non Medicare Eyewear	10		000000000000000000000100	1	200.00	2			2		2		2							
H3916	022	0	1	04	01	H3916_022_0	9	11	Hearing Aids	10		000000000000000000000001	1	500.00	2			2		2		2							
H3916	022	0	1	04	01	H3916_022_0	9	12	Diabetes Self Management Training	01	0000000000000000000000000000000100000		2		2			2		1	2	2					1	30.00	45.00
H3916	024	0	1	04	01	H3916_024_0	9	1	Copay and Coinsurance	11	0000000000000001111100000000000000100	000000000000000000001000	2		2			2		1	2	1		30		30	1	30.00	45.00
H3916	024	0	1	04	01	H3916_024_0	9	8	Specialist Physician	01	0000000001000000000000000000000000000		2		1	45.00	45.00	2		2		2							
H3916	024	0	1	04	01	H3916_024_0	9	7	Primary Care Physician	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H3916	024	0	1	04	01	H3916_024_0	9	6	Fitness Benefit	10		000000000000000010000000	2		2			1	500.00	2		1		50		50			
H3916	024	0	1	04	01	H3916_024_0	9	5	Transportation and Preventive Dental	10		000000010000000000100000	2		2			2		2		1		50		50			
H3916	024	0	1	04	01	H3916_024_0	9	9	End Stage Renal and Part B Drugs	01	0000000000000000000000000000100010000		2		2			2		2		1		0		30			
H3916	024	0	1	04	01	H3916_024_0	9	3	Coinsurance	11	0111110110111110000011110111000001011	000011100000000000000010	2		2			2		2		1		30		30			
H3916	024	0	1	04	01	H3916_024_0	9	2	Preventive Services	01	0000000000000000000000000000011000000		2		2			2		2		2							
H3916	024	0	1	04	01	H3916_024_0	9	12	Diabetes Self Management Training	01	0000000000000000000000000000000100000		2		2			2		1	2	2					1	30.00	45.00
H3916	024	0	1	04	01	H3916_024_0	9	11	Hearing Aids	10		000000000000000000000001	1	500.00	2			2		2		2							
H3916	024	0	1	04	01	H3916_024_0	9	10	Non Medicare Eyewear	10		000000000000000000000100	1	200.00	2			2		2		2							
H3916	024	0	1	04	01	H3916_024_0	9	4	Ambulance	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		1		30		30			
H3916	025	0	1	04	01	H3916_025_0	14	4	Group 4	11	0111111111111110000011110000000001011	000000100000000000000010	2		2			2		2		1		30		30			
H3916	025	0	1	04	01	H3916_025_0	14	3	Group 3	01	0000000000000000000000000000000100000		2		2			2		1	1	2	30		30		2		
H3916	025	0	1	04	01	H3916_025_0	14	2	Group 2	11	0000000000000000011100000000000000000	000000000000000000001000	2		2			2		1	1	1	30	30	30	30	2		
H3916	025	0	1	04	01	H3916_025_0	14	11	Group 11	01	0000000000000000000000000111000000000		2		2			2		2		1		20		20			
H3916	025	0	1	04	01	H3916_025_0	14	10	Group 10	10		000000000000000000000001	1	500.00	2			2		2		2							
H3916	025	0	1	04	01	H3916_025_0	14	1	Group 1	01	0000000000000001100000000000000000100		2		2			2		1	1	1	30	0	30	30	2		
H3916	025	0	1	04	01	H3916_025_0	14	5	Group 5	10		000000010000000010100000	2		2			2		2		1		50		50			
H3916	025	0	1	04	01	H3916_025_0	14	9	Group 9	10		000000000000000000000100	1	200.00	2			2		2		2							
H3916	025	0	1	04	01	H3916_025_0	14	8	Group 8	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		1		30		30			
H3916	025	0	1	04	01	H3916_025_0	14	7	Group 7	01	0000000000000000000000000000100010000		2		2			2		2		1		0		30			
H3916	025	0	1	04	01	H3916_025_0	14	6	Group 6	01	0000000000000000000000000000011000000		2		2			2		2		2							
H3916	032	0	1	04	01	H3916_032_0	10	1	Copay and Coinsurance	11	0000000000000001111100000000000000100	000000000000000000001000	2		2			2		1	2	1		30		30	1	30.00	50.00
H3916	032	0	1	04	01	H3916_032_0	10	10	Non Medicare Eyewear	10		000000000000000000000100	1	200.00	2			2		2		2							
H3916	032	0	1	04	01	H3916_032_0	10	11	Hearing Aids	10		000000000000000000000001	1	500.00	2			2		2		2							
H3916	032	0	1	04	01	H3916_032_0	10	12	Diabetes Self Management Training	01	0000000000000000000000000000000100000		2		2			2		1	2	2					1	30.00	50.00
H3916	032	0	1	04	01	H3916_032_0	10	2	Preventive Services	01	0000000000000000000000000000011000000		2		2			2		2		2							
H3916	032	0	1	04	01	H3916_032_0	10	9	End Stage Renal and Part B Drugs	01	0000000000000000000000000000100010000		2		2			2		2		1		0		30			
H3916	032	0	1	04	01	H3916_032_0	10	4	Ambulance	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		1		30		30			
H3916	032	0	1	04	01	H3916_032_0	10	5	Transportation and Preventive Dental	10		000000010000000000100000	2		2			2		2		1		50		50			
H3916	032	0	1	04	01	H3916_032_0	10	6	Fitness Benefit	10		000000000000000010000000	2		2			1	500.00	2		1		50		50			
H3916	032	0	1	04	01	H3916_032_0	10	7	Primary Care Physician	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H3916	032	0	1	04	01	H3916_032_0	10	8	Specialist Physician	01	0000000001000000000000000000000000000		2		1	50.00	50.00	2		2		2							
H3916	032	0	1	04	01	H3916_032_0	10	3	Coinsurance	11	0111110110111110000011110111000001011	000000100000000000000010	2		2			2		2		1		30		30			
H3916	033	0	1	04	01	H3916_033_0	9	1	Copay and Coinsurance	11	0000000000000001111100000000000000100	000000000000000000001000	2		2			2		1	2	1		30		30	1	30.00	50.00
H3916	033	0	1	04	01	H3916_033_0	9	7	Primary Care Physician	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H3916	033	0	1	04	01	H3916_033_0	9	10	Non Medicare Eyewear	10		000000000000000000000100	1	200.00	2			2		2		2							
H3916	033	0	1	04	01	H3916_033_0	9	11	Hearing Aids	10		000000000000000000000001	1	500.00	2			2		2		2							
H3916	033	0	1	04	01	H3916_033_0	9	12	Diabetes Self Management Training	01	0000000000000000000000000000000100000		2		2			2		1	2	2					1	30.00	50.00
H3916	033	0	1	04	01	H3916_033_0	9	2	Preventive Services	01	0000000000000000000000000000011000000		2		2			2		2		2							
H3916	033	0	1	04	01	H3916_033_0	9	3	Coinsurance	11	0111110110111110000011110111000001011	000000100000000000000010	2		2			2		2		1		30		30			
H3916	033	0	1	04	01	H3916_033_0	9	4	Ambulance	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		1		30		30			
H3916	033	0	1	04	01	H3916_033_0	9	5	Transportation and Preventive Dental	10		000000010000000000100000	2		2			2		2		1		50		50			
H3916	033	0	1	04	01	H3916_033_0	9	6	Fitness Benefit	10		000000000000000010000000	2		2			1	500.00	2		1		50		50			
H3916	033	0	1	04	01	H3916_033_0	9	9	End Stage Renal and Part B Drugs	01	0000000000000000000000000000100010000		2		2			2		2		1		0		30			
H3916	033	0	1	04	01	H3916_033_0	9	8	Specialist Physician	01	0000000001000000000000000000000000000		2		1	50.00	50.00	2		2		2							
H3916	801	0	1	04	01	H3916_801_0	7	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H3916	801	0	1	04	01	H3916_801_0	7	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H3916	802	0	1	04	01	H3916_802_0	7	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H3916	802	0	1	04	01	H3916_802_0	7	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H3916	804	0	1	04	01	H3916_804_0	7	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H3916	804	0	1	04	01	H3916_804_0	7	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H3921	001	0	1	04	01	H3921_001_0	2	1	Group 1	01	0000001000000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H3921	001	0	1	04	01	H3921_001_0	2	10	Group 10	11	0000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H3921	001	0	1	04	01	H3921_001_0	2	9	Group 9	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H3921	001	0	1	04	01	H3921_001_0	2	8	Group 8	01	0000000000100100000000100000000000000		2		1	35.00	45.00	2		2		2							
H3921	001	0	1	04	01	H3921_001_0	2	7	Group 7	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H3921	001	0	1	04	01	H3921_001_0	2	6	Group 6	01	0000100000000000000000000000000000000		2		1	75.00	75.00	2		2		2							
H3921	001	0	1	04	01	H3921_001_0	2	5	Group 5	01	0000010000000000000000000000000000000		2		2			2		2		1		45		45			
H3921	001	0	1	04	01	H3921_001_0	2	4	Group 4	01	0000000000000001111100000000000000000		2		1	13.00	21.00	2		1	2	1		30		30	1	20.00	50.00
H3921	001	0	1	04	01	H3921_001_0	2	3	Group 3	11	0000000000000000000011000011001110010	000000000000000100000000	2		2			2		2		1		30		30			
H3921	001	0	1	04	01	H3921_001_0	2	2	Group 2	11	0111000111010010000000000000000001101	000001000000000000001010	2		1	50.00	50.00	2		2		2							
H3921	001	0	1	04	01	H3921_001_0	2	14	Group 14	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H3921	001	0	1	04	01	H3921_001_0	2	13	Group 13	01	0000000000001000000000000000000000000		2		1	20.00	50.00	2		2		2							
H3921	001	0	1	04	01	H3921_001_0	2	12	Group 12	01	0000000000000000000000000100000000000		2		2			2		2		1		50		50			
H3921	001	0	1	04	01	H3921_001_0	2	11	Group 11	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H3921	008	0	1	04	01	H3921_008_0	2	1	Group 1	01	0000001000000000000000000000000000000		2		1	45.00	45.00	2		2		2							
H3921	008	0	1	04	01	H3921_008_0	2	8	Group 8	01	0000000000100100000000100000000000000		2		1	35.00	45.00	2		2		2							
H3921	008	0	1	04	01	H3921_008_0	2	7	Group 7	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H3921	008	0	1	04	01	H3921_008_0	2	6	Group 6	01	0000100000000000000000000000000000000		2		1	75.00	75.00	2		2		2							
H3921	008	0	1	04	01	H3921_008_0	2	5	Group 5	01	0000010000000000000000000000000000000		2		2			2		2		1		45		45			
H3921	008	0	1	04	01	H3921_008_0	2	4	Group 4	01	0000000000000001111100000000000000000		2		1	13.00	21.00	2		1	2	1		40		40	1	45.00	70.00
H3921	008	0	1	04	01	H3921_008_0	2	9	Group 9	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H3921	008	0	1	04	01	H3921_008_0	2	2	Group 2	11	0111000111010010000000000000000001101	000001000000000000001010	2		1	70.00	70.00	2		2		2							
H3921	008	0	1	04	01	H3921_008_0	2	14	Group 14	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H3921	008	0	1	04	01	H3921_008_0	2	13	Group 13	01	0000000000001000000000000000000000000		2		1	45.00	70.00	2		2		2							
H3921	008	0	1	04	01	H3921_008_0	2	12	Group 12	01	0000000000000000000000000100000000000		2		2			2		2		1		50		50			
H3921	008	0	1	04	01	H3921_008_0	2	11	Group 11	01	0000000000000000000000000000010000000		2		2			2		2		1		0		40			
H3921	008	0	1	04	01	H3921_008_0	2	10	Group 10	11	0000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H3921	008	0	1	04	01	H3921_008_0	2	3	Group 3	11	0000000000000000000011000011001110010	000000000000000100000000	2		2			2		2		1		40		40			
H3921	009	0	1	04	01	H3921_009_0	2	13	Group 13	01	0000000000001000000000000000000000000		2		1	15.00	55.00	2		2		2							
H3921	009	0	1	04	01	H3921_009_0	2	14	Group 14	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H3921	009	0	1	04	01	H3921_009_0	2	2	Group 2	11	0111000111010010000000000000000001101	000001000000000000001010	2		1	55.00	55.00	2		2		2							
H3921	009	0	1	04	01	H3921_009_0	2	3	Group 3	11	0000000000000000000011000011001110010	000000000000000100000000	2		2			2		2		1		30		30			
H3921	009	0	1	04	01	H3921_009_0	2	4	Group 4	01	0000000000000001111100000000000000000		2		1	13.00	21.00	2		1	2	1		30		30	1	15.00	55.00
H3921	009	0	1	04	01	H3921_009_0	2	5	Group 5	01	0000010000000000000000000000000000000		2		2			2		2		1		45		45			
H3921	009	0	1	04	01	H3921_009_0	2	6	Group 6	01	0000100000000000000000000000000000000		2		1	75.00	75.00	2		2		2							
H3921	009	0	1	04	01	H3921_009_0	2	7	Group 7	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H3921	009	0	1	04	01	H3921_009_0	2	8	Group 8	01	0000000000100100000000100000000000000		2		1	35.00	45.00	2		2		2							
H3921	009	0	1	04	01	H3921_009_0	2	9	Group 9	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H3921	009	0	1	04	01	H3921_009_0	2	1	Group 1	01	0000001000000000000000000000000000000		2		1	15.00	15.00	2		2		2							
H3921	009	0	1	04	01	H3921_009_0	2	10	Group 10	11	0000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H3921	009	0	1	04	01	H3921_009_0	2	11	Group 11	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H3921	009	0	1	04	01	H3921_009_0	2	12	Group 12	01	0000000000000000000000000100000000000		2		2			2		2		1		50		50			
H3923	013	0	1	04	01	H3923_013_0	6	1	OON Medical Benefits	11	0111111111111111111111111111111111111	000000100000000010001000	2		2			2		2		1		30		30			
H3923	013	0	1	04	01	H3923_013_0	6	3	OON Eyewear	10		000000000000000000000100	1	40.00	2			2		2		2							
H3923	013	0	1	04	01	H3923_013_0	6	2	OON Fitness/Health Class Benefit	10		000000000000000010000000	2		2			2		2		1		50		50			
H3923	017	0	1	04	01	H3923_017_0	6	1	OON Medical Benefits	11	0111111111111111111111111111111111111	000000100000000010101010	2		2			2		2		1		30		30			
H3923	017	0	1	04	01	H3923_017_0	6	2	OON Fitness/Health Class Benefit	10		000000000000000010000000	2		2			2		2		1		50		50			
H3923	017	0	1	04	01	H3923_017_0	6	4	OON Hearing Aids	10		000000000000000000000001	1	400.00	2			2		2		2							
H3923	017	0	1	04	01	H3923_017_0	6	3	OON Eyewear	10		000000000000000000000100	1	40.00	2			2		2		2							
H3923	801	0	1	04	01	H3923_801_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H3923	801	0	1	04	01	H3923_801_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H3923	802	0	1	04	01	H3923_802_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H3923	802	0	1	04	01	H3923_802_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H3923	803	0	1	04	01	H3923_803_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H3923	803	0	1	04	01	H3923_803_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H3924	054	0	1	04	01	H3924_054_0	6	3	$0 cost sharing	01	0000000000000000000000000000000000010		2		2			2		2		2							
H3924	054	0	1	04	01	H3924_054_0	6	2	Annual routine physical exam	10		000000000000000100000000	2		1	20.00	20.00	2		2		2							
H3924	054	0	1	04	01	H3924_054_0	6	1	Out of Network 35% co-insurance	11	0111111111111111111111111111111111101	000001000000000000000000	2		2			2		2		1		35		35			
H3924	054	0	1	04	01	H3924_054_0	6	4	Nurseline	10		000000000000000010000000	1	90.00	2			2		2		2							
H3924	059	3	1	04	01	H3924_059_3	5	1	Out of Network $0 benefits	10		000000000000000010000000	1	90.00	2			2		2		2							
H3924	059	3	1	04	01	H3924_059_3	5	2	Out of Network 0% Coinsurance Benefit	01	0000000000000000000000000000000100000		2		2			2		2		2							
H3924	059	3	1	04	01	H3924_059_3	5	3	Out of Network 35% coinsurance benefit	11	0111111111111111111111110110111011111	000001000000000100000000	2		2			2		2		1		35		35			
H3924	059	3	1	04	01	H3924_059_3	5	4	Out of Network $200.00 Copayment Benefit	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H3924	059	3	1	04	01	H3924_059_3	5	5	Diabetics Supplies	01	0000000000000000000000000001000000000		2		2			2		2		1		0		35			
H3924	059	4	1	04	01	H3924_059_4	5	4	Out of Network $200.00 Copayment Benefit	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H3924	059	4	1	04	01	H3924_059_4	5	3	Out of Network 35% coinsurance benefit	11	0111111111111111111111110110111011111	000001000000000100000000	2		2			2		2		1		35		35			
H3924	059	4	1	04	01	H3924_059_4	5	2	Out of Network 0% Coinsurance Benefit	01	0000000000000000000000000000000100000		2		2			2		2		2							
H3924	059	4	1	04	01	H3924_059_4	5	1	Out of Network $0 benefits	10		000000000000000010000000	1	90.00	2			2		2		2							
H3924	059	4	1	04	01	H3924_059_4	5	5	Diabetics Supplies	01	0000000000000000000000000001000000000		2		2			2		2		1		0		35			
H3924	060	3	1	04	01	H3924_060_3	6	2	Medicare benefits with a 45% coinsurance	11	0111111111111111111111110110111011111	000001000000000100000000	2		2			2		2		1		45		45			
H3924	060	3	1	04	01	H3924_060_3	6	1	Out of Network $0 Copay Benefits	01	0000000000000000000000000000000100000		2		1	0.00	0.00	2		2		2							
H3924	060	3	1	04	01	H3924_060_3	6	3	Out of network $190.00 copayment	01	0000000000000000000000001000000000000		2		1	190.00	190.00	2		2		2							
H3924	060	3	1	04	01	H3924_060_3	6	4	Diabetic supplies and services	01	0000000000000000000000000001000000000		2		2			2		2		1		0		45			
H3924	060	3	1	04	01	H3924_060_3	6	5	Nurseline $0 Copayment	10		000000000000000010000000	1	90.00	2			2		2		2							
H3924	060	4	1	04	01	H3924_060_4	6	1	Out of Network $0 Copay Benefits	01	0000000000000000000000000000000100000		2		1	0.00	0.00	2		2		2							
H3924	060	4	1	04	01	H3924_060_4	6	2	Medicare benefits with a 45% coinsurance	11	0111111111111111111111110110111011111	000001000000000100000000	2		2			2		2		1		45		45			
H3924	060	4	1	04	01	H3924_060_4	6	3	Out of network $190.00 copayment	01	0000000000000000000000001000000000000		2		1	190.00	190.00	2		2		2							
H3924	060	4	1	04	01	H3924_060_4	6	4	Diabetic supplies and services	01	0000000000000000000000000001000000000		2		2			2		2		1		0		45			
H3924	060	4	1	04	01	H3924_060_4	6	5	Nurseline $0 Copayment	10		000000000000000010000000	1	90.00	2			2		2		2							
H3924	061	1	1	04	01	H3924_061_1	5	2	$0 Copay Benefits	01	0000010000000000000000000000000000010		2		2			2		2		2							
H3924	061	1	1	04	01	H3924_061_1	5	1	Ambulance	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H3924	061	1	1	04	01	H3924_061_1	5	3	35% Coinsurance  Out-of-Network	11	0111101111111111111111110111111111101	000001000000000100000000	2		2			2		2		1		0		35			
H3924	061	1	1	04	01	H3924_061_1	5	4	Nurseline	10		000000000000000010000000	1	90.00	2			2		2		2							
H3924	061	2	1	04	01	H3924_061_2	5	1	Ambulance	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H3924	061	2	1	04	01	H3924_061_2	5	2	$0 Copay Benefits	01	0000010000000000000000000000000000010		2		2			2		2		2							
H3924	061	2	1	04	01	H3924_061_2	5	3	35% Coinsurance  Out-of-Network	11	0111101111111111111111110111111111101	000001000000000100000000	2		2			2		2		1		0		35			
H3924	061	2	1	04	01	H3924_061_2	5	4	Nurseline	10		000000000000000010000000	1	90.00	2			2		2		2							
H3924	061	5	1	04	01	H3924_061_5	5	1	Ambulance	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H3924	061	5	1	04	01	H3924_061_5	5	2	$0 Copay Benefits	01	0000010000000000000000000000000000010		2		2			2		2		2							
H3924	061	5	1	04	01	H3924_061_5	5	4	Nurseline	10		000000000000000010000000	1	90.00	2			2		2		2							
H3924	061	5	1	04	01	H3924_061_5	5	3	35% Coinsurance  Out-of-Network	11	0111101111111111111111110111111111101	000001000000000100000000	2		2			2		2		1		0		35			
H3924	801	0	1	04	01	H3924_801_0	5	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H3924	801	0	1	04	01	H3924_801_0	5	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H3924	802	0	1	04	01	H3924_802_0	5	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H3924	802	0	1	04	01	H3924_802_0	5	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4005	001	0	1	04	01	H4005_001_0	8	6	Group 6	10		000000000000000000000001	1	500.00	2			2		2		2							
H4005	001	0	1	04	01	H4005_001_0	8	5	Group 5	10		000000000000000000000100	1	100.00	2			2		2		2							
H4005	001	0	1	04	01	H4005_001_0	8	4	Group 4	01	0000000000000000000000000100000000000		2		2			2		2		1		30		30			
H4005	001	0	1	04	01	H4005_001_0	8	3	Group 3	11	0000000000000000000000000000111000010	000000010100000010000000	2		2			2		2		2							
H4005	001	0	1	04	01	H4005_001_0	8	2	Group 2	11	0111000110110010000000100000000101000	000011000000000000000000	2		2			2		2		1		25		25			
H4005	001	0	1	04	01	H4005_001_0	8	1	Group 1	11	0000111001001101111111011011000010101	000000100000000000101010	2		2			2		2		1		20		20			
H4005	001	0	1	04	01	H4005_001_0	8	7	Group 7	10		000000000000000000010000	1	1000.00	2			2		2		1		25		25			
H4005	004	0	1	04	01	H4005_004_0	10	6	Group 6	10		000000000000000000000001	1	300.00	2			2		2		2							
H4005	004	0	1	04	01	H4005_004_0	10	5	Group 5	10		000000000000000000000100	1	200.00	2			2		2		2							
H4005	004	0	1	04	01	H4005_004_0	10	4	Group 4	01	0000000000000000000000000110000000000		2		2			2		2		1		30		30			
H4005	004	0	1	04	01	H4005_004_0	10	3	Group 3	11	0000000000000000000000000000111000010	000000010100000010000000	2		2			2		2		2							
H4005	004	0	1	04	01	H4005_004_0	10	2	Group 2	11	0111000110110010000000100000000101000	000011001000000000000000	2		2			2		2		1		25		25			
H4005	004	0	1	04	01	H4005_004_0	10	1	Group 1	11	0000111001001101111111011001000010101	000000100000000001101010	2		2			2		2		1		20		20			
H4005	004	0	1	04	01	H4005_004_0	10	7	Group 7	10		000000000000000000010000	1	1000.00	2			2		2		1		25		25			
H4005	801	0	1	04	01	H4005_801_0	7	1	Group 1	01	0000010000000000000000000000010000000		2		2			2		2		2							
H4005	801	0	1	04	01	H4005_801_0	7	2	Group 2	01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4005	802	0	1	04	01	H4005_802_0	6	1	Group 1	01	0000010000000000000000000000010000000		2		2			2		2		2							
H4005	802	0	1	04	01	H4005_802_0	6	2	Group 2	11	0111101111111111111111111111101111111	000000000000000001000000	2		2			2		2		1		20		20			
H4005	804	0	1	04	01	H4005_804_0	6	1	Group 1	01	0000010000000000000000000000010000000		2		2			2		2		2							
H4005	804	0	1	04	01	H4005_804_0	6	2	Group 2	11	0111101111111111111111111111101111111	000000000000000001000000	2		2			2		2		1		20		20			
H4005	807	0	1	04	01	H4005_807_0	6	1	Group 1	01	0000010000000000000000000000010000000		2		2			2		2		2							
H4005	807	0	1	04	01	H4005_807_0	6	2	Group 2	11	0111101111111111111111111111101111111	000000000000000001000000	2		2			2		2		1		20		20			
H4011	001	0	1	04	01	H4011_001_0	9	1	20% coinsurance Group	11	0111011111011011111111011111010011111	000011100000000010101010	2		2			2		2		1		20		20			
H4011	001	0	1	04	01	H4011_001_0	9	2	50% coinsurance Group	01	0000100000100100000000100000000000000		2		2			2		2		1		50		50			
H4011	001	0	1	04	01	H4011_001_0	9	3	50% Coinsurance With Max	10		000000000000000000000100	1	100.00	2			2		2		1		50		50			
H4011	001	0	1	04	01	H4011_001_0	9	4	$O coinsurance Group with limits	10		000000000000000000000001	1	300.00	2			2		2		2							
H4011	001	0	1	04	01	H4011_001_0	9	5	0% Coinsurance Group	11	0000000000000000000000000000101100000	000000000100000000000000	2		2			2		2		2							
H4011	003	0	1	04	01	H4011_003_0	11	4	$O coinsurance Group with limits	10		000000000000000000000001	1	300.00	2			2		2		2							
H4011	003	0	1	04	01	H4011_003_0	11	5	0% Coinsurance Group	11	0000000000000000000000000000101100000	000000000100000000000000	2		2			2		2		2							
H4011	003	0	1	04	01	H4011_003_0	11	1	20% coinsurance Group	11	0111011111011011111111011111010011111	000011100000000010101010	2		2			2		2		1		20		20			
H4011	003	0	1	04	01	H4011_003_0	11	2	50% coinsurance Group	01	0000100000100100000000100000000000000		2		2			2		2		1		50		50			
H4011	003	0	1	04	01	H4011_003_0	11	3	50% Coinsurance With Max	10		000000000000000000000100	1	100.00	2			2		2		1		50		50			
H4011	801	0	1	04	01	H4011_801_0	8	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4011	801	0	1	04	01	H4011_801_0	8	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4011	803	0	1	04	01	H4011_803_0	8	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4011	803	0	1	04	01	H4011_803_0	8	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4011	805	0	1	04	01	H4011_805_0	8	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4011	805	0	1	04	01	H4011_805_0	8	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4011	807	0	1	04	01	H4011_807_0	8	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4011	807	0	1	04	01	H4011_807_0	8	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4011	809	0	1	04	01	H4011_809_0	8	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4011	809	0	1	04	01	H4011_809_0	8	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4011	811	0	1	04	01	H4011_811_0	8	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4011	811	0	1	04	01	H4011_811_0	8	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4011	813	0	1	04	01	H4011_813_0	8	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4011	813	0	1	04	01	H4011_813_0	8	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4011	815	0	1	04	01	H4011_815_0	8	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4011	815	0	1	04	01	H4011_815_0	8	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4011	817	0	1	04	01	H4011_817_0	8	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4011	817	0	1	04	01	H4011_817_0	8	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4011	820	0	1	04	01	H4011_820_0	8	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4011	820	0	1	04	01	H4011_820_0	8	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4011	821	0	1	04	01	H4011_821_0	8	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4011	821	0	1	04	01	H4011_821_0	8	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4011	822	0	1	04	01	H4011_822_0	8	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4011	822	0	1	04	01	H4011_822_0	8	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4011	823	0	1	04	01	H4011_823_0	8	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4011	823	0	1	04	01	H4011_823_0	8	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4011	824	0	1	04	01	H4011_824_0	8	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4011	824	0	1	04	01	H4011_824_0	8	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4011	825	0	1	04	01	H4011_825_0	8	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4011	825	0	1	04	01	H4011_825_0	8	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4036	008	0	1	04	01	H4036_008_0	12	10	Ambulance	01	0000000000000000000000001000000000000		2		1	275.00	275.00	2		2		2							
H4036	008	0	1	04	01	H4036_008_0	12	9	Labs	01	0000000000000000100000000000000000000		2		1	20.00	20.00	2		1	2	2					1	40.00	50.00
H4036	008	0	1	04	01	H4036_008_0	12	11	20%	11	0000000000000000000000000000100000000	000000000000000000100000	2		2			2		2		1		20		20			
H4036	008	0	1	04	01	H4036_008_0	12	12	Preventive	01	0000000000000000000000000000010000000		2		1	0.00	50.00	2		2		2							
H4036	008	0	1	04	01	H4036_008_0	12	13	Hearing	01	0000000000000000000000000000000000001		2		1	50.00	50.00	2		2		2							
H4036	008	0	1	04	01	H4036_008_0	12	14	Eye	10		000000000000000000001000	1	69.00	1	0.00	0.00	2		2		2							
H4036	008	0	1	04	01	H4036_008_0	12	15	Diag	01	0000000000000000010000000000000000000		2		1	180.00	200.00	2		2		2							
H4036	008	0	1	04	01	H4036_008_0	12	2	Therapeutic	01	0000000000000000001000000000000000000		2		2			2		2		1		20		20			
H4036	008	0	1	04	01	H4036_008_0	12	3	Outpatient	01	0000000000000000000010000000000000000		2		1	40.00	50.00	2		2		1		30		30			
H4036	008	0	1	04	01	H4036_008_0	12	4	PCP	01	0000001000001000000000000000000000000		2		1	40.00	40.00	2		2		2							
H4036	008	0	1	04	01	H4036_008_0	12	5	$50	11	0000100001110100000000100000000000111	000000000000000100000000	2		1	50.00	50.00	2		2		2							
H4036	008	0	1	04	01	H4036_008_0	12	6	DME/ASC	01	0000000000000000000001000111000010000		2		2			2		2		1		30		30			
H4036	008	0	1	04	01	H4036_008_0	12	7	$50	01	0111000110000010000000000000000000000		2		1	50.00	50.00	2		2		2							
H4036	008	0	1	04	01	H4036_008_0	12	8	Radiology	01	0000000000000001000100000000000000000		2		1	140.00	200.00	2		1	2	2					1	40.00	50.00
H4036	008	0	1	04	01	H4036_008_0	12	1	$0	11	0000010000000000000000010000001101000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H4036	009	0	1	04	01	H4036_009_0	12	10	Ambulance	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H4036	009	0	1	04	01	H4036_009_0	12	1	$0	11	0000010000000000000000010000001101000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H4036	009	0	1	04	01	H4036_009_0	12	11	20%	11	0000000000000000000000000000100000000	000000000000000000100000	2		2			2		2		1		20		20			
H4036	009	0	1	04	01	H4036_009_0	12	9	Labs	01	0000000000000000100000000000000000000		2		2			2		1	2	1		20		20	1	20.00	50.00
H4036	009	0	1	04	01	H4036_009_0	12	8	Radiology	01	0000000000000001000100000000000000000		2		1	110.00	170.00	2		1	2	2					1	20.00	50.00
H4036	009	0	1	04	01	H4036_009_0	12	7	Diag	01	0000000000000000010000000000000000000		2		1	150.00	170.00	2		2		2							
H4036	009	0	1	04	01	H4036_009_0	12	6	DME	01	0000000000000000000000000111000010000		2		2			2		2		1		30		30			
H4036	009	0	1	04	01	H4036_009_0	12	5	$50	11	0111100111110110000000100000000000111	000000000000000100000000	2		1	50.00	50.00	2		2		2							
H4036	009	0	1	04	01	H4036_009_0	12	12	Preventive	01	0000000000000000000000000000010000000		2		1	0.00	50.00	2		2		2							
H4036	009	0	1	04	01	H4036_009_0	12	13	Hearing	01	0000000000000000000000000000000000001		2		1	50.00	50.00	2		2		2							
H4036	009	0	1	04	01	H4036_009_0	12	14	Eye	10		000000000000000000001000	1	69.00	1	0.00	0.00	2		2		2							
H4036	009	0	1	04	01	H4036_009_0	12	15	ASC	01	0000000000000000000001000000000000000		2		2			2		2		1		25		25			
H4036	009	0	1	04	01	H4036_009_0	12	2	Therapeutic	01	0000000000000000001000000000000000000		2		2			2		1	2	1		20		20	1	20.00	50.00
H4036	009	0	1	04	01	H4036_009_0	12	3	Outpatient	01	0000000000000000000010000000000000000		2		1	20.00	50.00	2		2		1		25		25			
H4036	009	0	1	04	01	H4036_009_0	12	4	PCP	01	0000001000001000000000000000000000000		2		1	20.00	20.00	2		2		2							
H4036	801	0	1	04	01	H4036_801_0	5	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4036	801	0	1	04	01	H4036_801_0	5	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4036	802	0	1	04	01	H4036_802_0	5	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4036	802	0	1	04	01	H4036_802_0	5	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4036	803	0	1	04	01	H4036_803_0	5	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4036	803	0	1	04	01	H4036_803_0	5	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4213	001	0	1	09	04	H4213_001_0	12	1	Ambulance	01	0000000000000000000000001000000000000		2		1	350.00	350.00	2		2		2							
H4213	001	0	1	09	04	H4213_001_0	12	10	Partial Hospitalization	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		1		30		30			
H4213	001	0	1	09	04	H4213_001_0	12	9	Mental/Psychiatric/PT/SP/Cardiac/pulmo	01	0111000010100110000000100000000000000		2		1	25.00	40.00	2		2		1		30		30			
H4213	001	0	1	09	04	H4213_001_0	12	8	Specialist/Dental/Hearing/other	01	0000000001001000000000000000000001011		2		1	40.00	40.00	2		2		1		30		30			
H4213	001	0	1	09	04	H4213_001_0	12	7	Diagnostic	01	0000000000000000010000000000000000000		2		1	250.00	250.00	2		1	1	1	30	30	30	30	1	40.00	40.00
H4213	001	0	1	09	04	H4213_001_0	12	6	Other Services	01	0000000000000001001100000111100010000		2		2			2		2		1		20		30			
H4213	001	0	1	09	04	H4213_001_0	12	5	Chiropractic/Podiatry	01	0000000100010000000000000000000000000		2		1	20.00	20.00	2		2		1		30		30			
H4213	001	0	1	09	04	H4213_001_0	12	4	Primary Care Physician	01	0000001000000000000000000000000000000		2		1	15.00	15.00	2		2		1		30		30			
H4213	001	0	1	09	04	H4213_001_0	12	3	Preventive Services/Blood/Home Health	11	0000010000000000000000010000011100000	000000000000000100000000	2		2			2		2		1		0		30			
H4213	001	0	1	09	04	H4213_001_0	12	2	Education/Wellness Programs	10		000000000000000010000000	1	750.00	2			1	250.00	2		1		50		50			
H4213	001	0	1	09	04	H4213_001_0	12	13	Eye Exam	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	40.00	2		2		1		30		30			
H4213	001	0	1	09	04	H4213_001_0	12	12	Outpatient/Ambulatory Services	01	0000000000000000000011000000000000000		2		2			2		2		1		20		30			
H4213	001	0	1	09	04	H4213_001_0	12	11	Laboratory Services	01	0000000000000000100000000000000000000		2		2			2		1	1	1	30	0	30	30	1	15.00	40.00
H4213	002	0	1	09	04	H4213_002_0	11	1	Ambulance	01	0000000000000000000000001000000000000		2		1	350.00	350.00	2		2		2							
H4213	002	0	1	09	04	H4213_002_0	11	8	Specialist/Dental/Hearing/other	01	0000000001001000000000000000000001011		2		1	40.00	40.00	2		2		1		30		30			
H4213	002	0	1	09	04	H4213_002_0	11	7	Diagnostic	01	0000000000000000010000000000000000000		2		1	250.00	250.00	2		1	1	1	30	30	30	30	1	15.00	40.00
H4213	002	0	1	09	04	H4213_002_0	11	6	Other Services	01	0000000000000001001100000111100010000		2		2			2		2		1		20		30			
H4213	002	0	1	09	04	H4213_002_0	11	5	Chiropractic/Podiatry	01	0000000100010000000000000000000000000		2		1	20.00	20.00	2		2		1		30		30			
H4213	002	0	1	09	04	H4213_002_0	11	4	Primary Care Physician	01	0000001000000000000000000000000000000		2		1	15.00	15.00	2		2		1		30		30			
H4213	002	0	1	09	04	H4213_002_0	11	9	Mental/Psychiatric/PT/SP/Cardiac/pulmo	01	0111000010100110000000100000000000000		2		1	25.00	40.00	2		2		1		30		30			
H4213	002	0	1	09	04	H4213_002_0	11	2	Education/Wellness Programs	10		000000000000000010000000	1	750.00	2			1	250.00	2		1		50		50			
H4213	002	0	1	09	04	H4213_002_0	11	13	Eye Exams	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	40.00	2		2		1		30		30			
H4213	002	0	1	09	04	H4213_002_0	11	12	Outpatient/Ambulatory Services	01	0000000000000000000011000000000000000		2		2			2		2		1		20		30			
H4213	002	0	1	09	04	H4213_002_0	11	11	Laboratory Services	01	0000000000000000100000000000000000000		2		2			2		1	1	1	30	0	30	30	1	15.00	40.00
H4213	002	0	1	09	04	H4213_002_0	11	10	Partial Hospitalization	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		1		30		30			
H4213	002	0	1	09	04	H4213_002_0	11	3	Preventive Services/Blood/Home Health	11	0000010000000000000000010000011100000	000000000000000100000000	2		2			2		2		1		0		30			
H4213	004	0	1	09	04	H4213_004_0	15	6	Other Services	01	0000000000000001001100000111100010000		2		2			2		2		1		20		30			
H4213	004	0	1	09	04	H4213_004_0	15	7	Diagnostic	01	0000000000000000010000000000000000000		2		1	315.00	315.00	2		1	1	1	30	30	30	30	1	20.00	50.00
H4213	004	0	1	09	04	H4213_004_0	15	8	Specialist/Dental/Hearing/other	01	0000000001001000000000000000000001011		2		1	50.00	50.00	2		2		1		30		30			
H4213	004	0	1	09	04	H4213_004_0	15	9	Mental/Psychiatric/PT/SP/Cardiac/pulmo	01	0111000010100110000000100000000000000		2		1	25.00	40.00	2		2		1		30		30			
H4213	004	0	1	09	04	H4213_004_0	15	1	Ambulance	01	0000000000000000000000001000000000000		2		1	350.00	350.00	2		2		2							
H4213	004	0	1	09	04	H4213_004_0	15	10	Partial Hospitalization	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		1		30		30			
H4213	004	0	1	09	04	H4213_004_0	15	11	Laboratory Services	01	0000000000000000100000000000000000000		2		2			2		1	1	1	30	0	30	30	1	20.00	50.00
H4213	004	0	1	09	04	H4213_004_0	15	12	Outpatient/Ambulatory Services	01	0000000000000000000011000000000000000		2		2			2		2		1		20		30			
H4213	004	0	1	09	04	H4213_004_0	15	13	Eye Exams	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	50.00	2		2		1		30		30			
H4213	004	0	1	09	04	H4213_004_0	15	2	Education/Wellness Programs	10		000000000000000010000000	1	750.00	2			1	250.00	2		1		50		50			
H4213	004	0	1	09	04	H4213_004_0	15	3	Preventive Services/Blood/Home Health	11	0000010000000000000000010000011100000	000000000000000100000000	2		2			2		2		1		0		30			
H4213	004	0	1	09	04	H4213_004_0	15	4	Primary Care Physician	01	0000001000000000000000000000000000000		2		1	20.00	20.00	2		2		1		30		30			
H4213	004	0	1	09	04	H4213_004_0	15	5	Chiropractic/Podiatry	01	0000000100010000000000000000000000000		2		1	20.00	20.00	2		2		1		30		30			
H4213	005	0	1	09	04	H4213_005_0	13	1	Ambulance	01	0000000000000000000000001000000000000		2		1	350.00	350.00	2		2		2							
H4213	005	0	1	09	04	H4213_005_0	13	10	Partial Hospitalization	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		1		30		30			
H4213	005	0	1	09	04	H4213_005_0	13	11	Laboratory Services	01	0000000000000000100000000000000000000		2		2			2		1	1	1	30	0	30	30	1	25.00	50.00
H4213	005	0	1	09	04	H4213_005_0	13	12	Outpatient/Ambulatory Services	01	0000000000000000000011000000000000000		2		2			2		2		1		20		30			
H4213	005	0	1	09	04	H4213_005_0	13	13	Eye Exams	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	50.00	2		2		1		30		30			
H4213	005	0	1	09	04	H4213_005_0	13	2	Education/Wellness Programs	10		000000000000000010000000	1	750.00	2			1	250.00	2		1		50		50			
H4213	005	0	1	09	04	H4213_005_0	13	9	Mental/Psychiatric/PT/SP/Cardiac/pulmo	01	0111000010100110000000100000000000000		2		1	25.00	40.00	2		2		1		30		30			
H4213	005	0	1	09	04	H4213_005_0	13	4	Primary Care Physician	01	0000001000000000000000000000000000000		2		1	25.00	25.00	2		2		1		30		30			
H4213	005	0	1	09	04	H4213_005_0	13	5	Chiropractic/Podiatry	01	0000000100010000000000000000000000000		2		1	20.00	20.00	2		2		1		30		30			
H4213	005	0	1	09	04	H4213_005_0	13	6	Other Services	01	0000000000000001001100000111100010000		2		2			2		2		1		20		30			
H4213	005	0	1	09	04	H4213_005_0	13	7	Diagnostic	01	0000000000000000010000000000000000000		2		1	315.00	315.00	2		1	1	1	30	30	30	30	1	25.00	50.00
H4213	005	0	1	09	04	H4213_005_0	13	8	Specialist/Dental/Hearing/other	01	0000000001001000000000000000000001011		2		1	50.00	50.00	2		2		1		30		30			
H4213	005	0	1	09	04	H4213_005_0	13	3	Preventive Services/Blood/Home Health	11	0000010000000000000000010000011100000	000000000000000100000000	2		2			2		2		1		0		30			
H4522	001	0	1	04	01	H4522_001_0	2	13	Group 13	01	0000010000000000000000000100000000000		2		2			2		2		1		50		50			
H4522	001	0	1	04	01	H4522_001_0	2	12	Group 12	11	0000000000000000000011000000001100000	000000000000000100000000	2		2			2		2		1		40		40			
H4522	001	0	1	04	01	H4522_001_0	2	9	Group 9	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H4522	001	0	1	04	01	H4522_001_0	2	8	Group 8	01	0000000000100100000000100000000000000		2		1	35.00	45.00	2		2		2							
H4522	001	0	1	04	01	H4522_001_0	2	7	Group 7	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H4522	001	0	1	04	01	H4522_001_0	2	6	Group 6	01	0000100000000000000000000000000000000		2		1	75.00	75.00	2		2		2							
H4522	001	0	1	04	01	H4522_001_0	2	5	Group 5	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H4522	001	0	1	04	01	H4522_001_0	2	4	Group 4	01	0000000000000001111100000000000000000		2		1	13.00	21.00	2		1	2	1		40		40	1	30.00	65.00
H4522	001	0	1	04	01	H4522_001_0	2	3	Group 3	01	0000000000000000000000000011000010010		2		2			2		2		1		30		30			
H4522	001	0	1	04	01	H4522_001_0	2	2	Group 2	11	0111000111010010000000000000000001101	000001000000000000001010	2		1	65.00	65.00	2		2		2							
H4522	001	0	1	04	01	H4522_001_0	2	14	Group 14	01	0000000000001000000000000000000000000		2		1	30.00	65.00	2		2		2							
H4522	001	0	1	04	01	H4522_001_0	2	11	Group 11	01	0000000000000000000000000000010000000		2		2			2		2		1		0		40			
H4522	001	0	1	04	01	H4522_001_0	2	10	Group 10	11	0000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H4522	001	0	1	04	01	H4522_001_0	2	1	Group 1	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H4522	007	0	1	04	01	H4522_007_0	3	5	Group 5	10		000000010000000000000000	2		2			2		2		1		75		75			
H4522	007	0	1	04	01	H4522_007_0	3	4	Group 4	11	0000000000000000000000000000000000010	000000000000000010010000	2		1	0.00	0.00	2		2		2							
H4522	007	0	1	04	01	H4522_007_0	3	3	Group 3	01	0000000000000000000000001000100000000		2		2			2		2		1		20		20			
H4522	007	0	1	04	01	H4522_007_0	3	7	Group 7	10		000000000100000000000000	1	100.00	1	0.00	0.00	2		2		2							
H4522	007	0	1	04	01	H4522_007_0	3	6	Group 6	01	0000000000000001111100000000000000000		2		2			2		1	1	1	30	0	30	30	2		
H4522	007	0	1	04	01	H4522_007_0	3	9	Group 9	10		000000000000000000000100	1	150.00	1	0.00	0.00	2		2		2							
H4522	007	0	1	04	01	H4522_007_0	3	2	Group 2	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H4522	007	0	1	04	01	H4522_007_0	3	10	Group 10	10		000000000000000000000001	1	2000.00	1	0.00	0.00	2		2		2							
H4522	007	0	1	04	01	H4522_007_0	3	1	Group 1	11	0111111111111110000011110111001111101	000001100000000000001010	2		2			2		2		1		30		30			
H4522	007	0	1	04	01	H4522_007_0	3	8	Group 8	10		000000000000000000100000	1	2000.00	1	0.00	0.00	2		2		2							
H4522	010	0	1	04	01	H4522_010_0	3	5	Group 5	01	0000000000000001111100000000000000000		2		2			2		1	1	1	30	0	30	30	2		
H4522	010	0	1	04	01	H4522_010_0	3	4	Group 4	11	0000000000000000000000000000000000010	000000000000000000010000	2		1	0.00	0.00	2		2		2							
H4522	010	0	1	04	01	H4522_010_0	3	3	Group 3	01	0000000000000000000000001000100000000		2		2			2		2		1		20		20			
H4522	010	0	1	04	01	H4522_010_0	3	2	Group 2	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H4522	010	0	1	04	01	H4522_010_0	3	1	Group 1	11	0111111111111110000011110111001111101	000001100000000000001010	2		2			2		2		1		30		30			
H4522	010	0	1	04	01	H4522_010_0	3	9	Group 9	10		000000000000000000000001	1	2000.00	1	0.00	0.00	2		2		2							
H4522	010	0	1	04	01	H4522_010_0	3	6	Group 6	10		000000000100000000000000	1	90.00	1	0.00	0.00	2		2		2							
H4522	010	0	1	04	01	H4522_010_0	3	7	Group 7	10		000000000000000000100000	1	2000.00	1	0.00	0.00	2		2		2							
H4522	010	0	1	04	01	H4522_010_0	3	8	Group 8	10		000000000000000000000100	1	150.00	1	0.00	0.00	2		2		2							
H4605	001	0	1	04	01	H4605_001_0	8	5	$0 to $350 copay	01	0000000000000000000010000000000000000		2		1	0.00	350.00	2		2		2							
H4605	001	0	1	04	01	H4605_001_0	8	4	0 - Zero cost share	11	0000100000000001100000010001011100010	000000100000000110000000	2		2			2		2		2							
H4605	001	0	1	04	01	H4605_001_0	8	3	Dental Preventive Services $500 maximum	10		000000000000000000100000	1	500.00	2			2		2		1		50		50			
H4605	001	0	1	04	01	H4605_001_0	8	2	$55 copay	01	0111000011101110000000100000000001101		2		1	55.00	55.00	2		2		2							
H4605	001	0	1	04	01	H4605_001_0	8	12	30% coinsurance	01	0000000000000000011000000110000000000		2		2			2		2		1		30		30			
H4605	001	0	1	04	01	H4605_001_0	8	9	$250 copay	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H4605	001	0	1	04	01	H4605_001_0	8	10	10% coinsurance	01	0000000000000000000000000000100000000		2		2			2		2		1		10		10			
H4605	001	0	1	04	01	H4605_001_0	8	1	$25 copay	01	0000001100010000000000000000000000000		2		1	25.00	25.00	2		2		2							
H4605	001	0	1	04	01	H4605_001_0	8	6	$0 to $300 copay	01	0000000000000000000001000000000000000		2		1	0.00	300.00	2		2		2							
H4605	001	0	1	04	01	H4605_001_0	8	7	$35 copay VSP exam	10		000000000000000000001000	2		1	35.00	35.00	2		2		2							
H4605	001	0	1	04	01	H4605_001_0	8	8	VSP Eyewear $100 Maximum	10		000000000000000000000100	1	100.00	2			2		2		2							
H4605	001	0	1	04	01	H4605_001_0	8	11	20% coinsurance	01	0000010000000000000100000000000010000		2		2			2		2		1		20		20			
H4605	002	0	1	04	01	H4605_002_0	9	5	$0 to $350 copay	01	0000000000000000000010000000000000000		2		1	0.00	350.00	2		2		2							
H4605	002	0	1	04	01	H4605_002_0	9	4	0 - Zero cost share	11	0000100000000001100000010001011100010	000000100000000110000000	2		2			2		2		2							
H4605	002	0	1	04	01	H4605_002_0	9	3	Dental Preventive Services $500 maximum	10		000000000000000000100000	1	500.00	2			2		2		1		50		50			
H4605	002	0	1	04	01	H4605_002_0	9	2	$55 copay	01	0111000011101110000000100000000001101		2		1	55.00	55.00	2		2		2							
H4605	002	0	1	04	01	H4605_002_0	9	12	30% coinsurance	01	0000000000000000011000000110000000000		2		2			2		2		1		30		30			
H4605	002	0	1	04	01	H4605_002_0	9	11	20% coinsurance	11	0000010000000000000100000000000010000	000000000000000001000000	2		2			2		2		1		20		20			
H4605	002	0	1	04	01	H4605_002_0	9	10	10% coinsurance	01	0000000000000000000000000000100000000		2		2			2		2		1		10		10			
H4605	002	0	1	04	01	H4605_002_0	9	1	$25 copay	01	0000001100010000000000000000000000000		2		1	25.00	25.00	2		2		2							
H4605	002	0	1	04	01	H4605_002_0	9	6	$0 to $300 copay	01	0000000000000000000001000000000000000		2		1	0.00	300.00	2		2		2							
H4605	002	0	1	04	01	H4605_002_0	9	9	$250 copay	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H4605	002	0	1	04	01	H4605_002_0	9	8	VSP Eyewear $100 Maximum	10		000000000000000000000100	1	100.00	2			2		2		2							
H4605	002	0	1	04	01	H4605_002_0	9	7	$35 copay VSP exam	10		000000000000000000001000	2		1	35.00	35.00	2		2		2							
H4605	004	0	1	04	01	H4605_004_0	9	1	$20 copay	01	0000001100010000000000000000000000000		2		1	20.00	20.00	2		2		2							
H4605	004	0	1	04	01	H4605_004_0	9	10	10% coinsurance	11	0000010000000000000100000000100010000	000000000000000001000000	2		2			2		2		1		10		10			
H4605	004	0	1	04	01	H4605_004_0	9	9	$250 copay	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H4605	004	0	1	04	01	H4605_004_0	9	8	VSP Eyewear $200 Maximum	10		000000000000000000000100	1	200.00	2			2		2		2							
H4605	004	0	1	04	01	H4605_004_0	9	7	$25 copay VSP exam	10		000000000000000000001000	2		1	25.00	25.00	2		2		2							
H4605	004	0	1	04	01	H4605_004_0	9	11	20% coinsurance	01	0000000000000000001000000110000000000		2		2			2		2		1		20		20			
H4605	004	0	1	04	01	H4605_004_0	9	12	Hearing Aid - $500 maximum	10		000000000000000000000001	1	500.00	2			2		2		2							
H4605	004	0	1	04	01	H4605_004_0	9	13	30% coinsurance	01	0000000000000000010000000000000000000		2		2			2		2		1		30		30			
H4605	004	0	1	04	01	H4605_004_0	9	2	$40 copay	01	0111000011101110000000100000000001101		2		1	40.00	40.00	2		2		2							
H4605	004	0	1	04	01	H4605_004_0	9	3	Dental Preventive Services $500 maximum	10		000000000000000000100000	1	500.00	2			2		2		1		50		50			
H4605	004	0	1	04	01	H4605_004_0	9	4	0 - Zero cost share	11	0000100000000001100000010001011100010	000000100000000110000000	2		2			2		2		2							
H4605	004	0	1	04	01	H4605_004_0	9	5	$0 to $250 copay	01	0000000000000000000010000000000000000		2		1	0.00	250.00	2		2		2							
H4605	004	0	1	04	01	H4605_004_0	9	6	$0 to $200 copay	01	0000000000000000000001000000000000000		2		1	0.00	200.00	2		2		2							
H4605	801	0	1	04	01	H4605_801_0	8	1	$0 copay	01	0000010000000000100000000000010000000		2		2			2		2		2							
H4605	801	0	1	04	01	H4605_801_0	8	2	20% coinsurance	01	0111101111111111011111111111101111111		2		2			2		2		1		20		20			
H4605	802	0	1	04	01	H4605_802_0	8	1	$0 copay	01	0000010000000000100000000000010000000		2		2			2		2		2							
H4605	802	0	1	04	01	H4605_802_0	8	2	20% coinsurance	01	0111101111111111011111111111101111111		2		2			2		2		1		20		20			
H4738	002	0	1	04	01	H4738_002_0	8	7	hearing aid	10		000000000000000000000001	1	500.00	2			2		2		1		50		50			
H4738	002	0	1	04	01	H4738_002_0	8	6	eyewear	10		000000000000000000000100	1	100.00	2			2		2		1		50		50			
H4738	002	0	1	04	01	H4738_002_0	8	5	50 non med	10		000000000000000010001010	2		2			2		2		1		50		50			
H4738	002	0	1	04	01	H4738_002_0	8	4	20 plus	01	0000000000000001111000000000000100000		2		2			2		1	1	1	20	20	20	20	2		
H4738	002	0	1	04	01	H4738_002_0	8	3	50	01	0000000000000000000000000000000001111		2		2			2		2		1		50		50			
H4738	002	0	1	04	01	H4738_002_0	8	2	23	01	0000000000000000000000000111000000000		2		2			2		2		1		23		23			
H4738	002	0	1	04	01	H4738_002_0	8	1	20 no	11	0111111111111110000111111000111010000	000000100000000000000000	2		2			2		2		1		20		20			
H4754	004	0	1	04	01	H4754_004_0	7	4	$0 copay	11	0000010000000000000000000000000000010	000000000000000010000000	2		2			2		2		2							
H4754	004	0	1	04	01	H4754_004_0	7	3	Specialist Copay	01	0000100001000000000000000000000000000		2		1	40.00	40.00	2		2		2							
H4754	004	0	1	04	01	H4754_004_0	7	2	PCP Copay	01	0000001000000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H4754	004	0	1	04	01	H4754_004_0	7	12	Lab	01	0000000000000000100000000000000000000		2		1	0.00	15.00	2		1	2	2					1	20.00	40.00
H4754	004	0	1	04	01	H4754_004_0	7	11	Diagnostic Testing	01	0000000000000001000000000000000000000		2		1	15.00	15.00	2		1	2	2					1	20.00	40.00
H4754	004	0	1	04	01	H4754_004_0	7	10	Eye wear - Routine	10		000000000000000000000100	1	100.00	2			2		2		2							
H4754	004	0	1	04	01	H4754_004_0	7	1	20% coinsurance	11	0111000110110110000000110111111111001	000000000000000100000010	2		2			2		2		1		20		20			
H4754	004	0	1	04	01	H4754_004_0	7	5	Outpatient Hospital	01	0000000000000000000010000000000000000		2		1	0.00	350.00	2		2		1		20		20			
H4754	004	0	1	04	01	H4754_004_0	7	9	Other health care professional	01	0000000000001000000000000000000000000		2		1	20.00	40.00	2		2		2							
H4754	004	0	1	04	01	H4754_004_0	7	8	Ambulance	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H4754	004	0	1	04	01	H4754_004_0	7	7	Office visit copay	11	0000000000000000011100000000000000100	000000000000000000001000	2		2			2		1	2	1		20		20	1	20.00	40.00
H4754	004	0	1	04	01	H4754_004_0	7	6	ASC	01	0000000000000000000001000000000000000		2		1	350.00	350.00	2		2		2							
H4754	006	0	1	04	01	H4754_006_0	8	1	20% coinsurance	11	0111000110110110000000110111111111001	000000000000000100000010	2		2			2		2		1		20		20			
H4754	006	0	1	04	01	H4754_006_0	8	10	$0 copay	11	0000000000000000000000000000000000010	000000000000000010000000	2		2			2		2		2							
H4754	006	0	1	04	01	H4754_006_0	8	11	Routine eyewear	10		000000000000000000000100	1	100.00	2			2		2		2							
H4754	006	0	1	04	01	H4754_006_0	8	2	PCP Copay	01	0000001000000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H4754	006	0	1	04	01	H4754_006_0	8	3	Specialist Copay	01	0000100001000000000000000000000000000		2		1	45.00	45.00	2		2		2							
H4754	006	0	1	04	01	H4754_006_0	8	9	Other health care professional	01	0000000000001000000000000000000000000		2		1	20.00	45.00	2		2		2							
H4754	006	0	1	04	01	H4754_006_0	8	8	Ambulance	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H4754	006	0	1	04	01	H4754_006_0	8	7	Office visit copay	11	0000000000000001111100000000000000100	000000000000000000001000	2		2			2		1	2	1		20		20	1	20.00	45.00
H4754	006	0	1	04	01	H4754_006_0	8	6	ASC	01	0000000000000000000001000000000000000		2		1	350.00	350.00	2		2		2							
H4754	006	0	1	04	01	H4754_006_0	8	5	Outpatient hospital	01	0000000000000000000010000000000000000		2		1	350.00	350.00	2		2		1		20		20			
H4754	006	0	1	04	01	H4754_006_0	8	4	10% coinsurance	01	0000010000000000000000000000000000000		2		2			2		2		1		10		10			
H4754	007	0	1	04	01	H4754_007_0	7	1	20% coinsurance	11	0111000110110110000000110111111111001	000000000000000100000010	2		2			2		2		1		20		20			
H4754	007	0	1	04	01	H4754_007_0	7	10	Routine eyewear	10		000000000000000000000100	1	100.00	2			2		2		2							
H4754	007	0	1	04	01	H4754_007_0	7	9	Other health care professional	01	0000000000001000000000000000000000000		2		1	25.00	45.00	2		2		2							
H4754	007	0	1	04	01	H4754_007_0	7	8	Ambulance	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H4754	007	0	1	04	01	H4754_007_0	7	7	Office visit copay	11	0000000000000001111100000000000000100	000000000000000000001000	2		2			2		1	2	1		20		20	1	25.00	45.00
H4754	007	0	1	04	01	H4754_007_0	7	6	ASC	01	0000000000000000000001000000000000000		2		1	350.00	350.00	2		2		2							
H4754	007	0	1	04	01	H4754_007_0	7	5	$0 copay	11	0000000000000000000000000000000000010	000000000000000010000000	2		2			2		2		2							
H4754	007	0	1	04	01	H4754_007_0	7	4	10% coinsurance	01	0000010000000000000000000000000000000		2		2			2		2		1		10		10			
H4754	007	0	1	04	01	H4754_007_0	7	3	Specialist Copay	01	0000100001000000000000000000000000000		2		1	45.00	45.00	2		2		2							
H4754	007	0	1	04	01	H4754_007_0	7	2	PCP Copay	01	0000001000000000000000000000000000000		2		1	25.00	25.00	2		2		2							
H4754	007	0	1	04	01	H4754_007_0	7	11	Outpatient Hospital	01	0000000000000000000010000000000000000		2		1	350.00	350.00	2		2		1		20		20			
H4754	008	0	1	04	01	H4754_008_0	8	1	20% coinsurance	11	0111000110110110000000110111111111001	000000000000000100000010	2		2			2		2		1		20		20			
H4754	008	0	1	04	01	H4754_008_0	8	10	Routine eyewear	10		000000000000000000000100	1	100.00	2			2		2		2							
H4754	008	0	1	04	01	H4754_008_0	8	9	Other health care professional	01	0000000000001000000000000000000000000		2		1	25.00	45.00	2		2		2							
H4754	008	0	1	04	01	H4754_008_0	8	8	Ambulance	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H4754	008	0	1	04	01	H4754_008_0	8	7	Office visit copay	11	0000000000000001111100000000000000100	000000000000000000001000	2		2			2		1	2	1		20		20	1	25.00	45.00
H4754	008	0	1	04	01	H4754_008_0	8	6	ASC	01	0000000000000000000001000000000000000		2		1	350.00	350.00	2		2		2							
H4754	008	0	1	04	01	H4754_008_0	8	5	$0 copay	11	0000000000000000000000000000000000010	000000000000000010000000	2		2			2		2		2							
H4754	008	0	1	04	01	H4754_008_0	8	4	10% coinsurance	01	0000010000000000000000000000000000000		2		2			2		2		1		10		10			
H4754	008	0	1	04	01	H4754_008_0	8	3	Specialist Copay	01	0000100001000000000000000000000000000		2		1	45.00	45.00	2		2		2							
H4754	008	0	1	04	01	H4754_008_0	8	2	PCP Copay	01	0000001000000000000000000000000000000		2		1	25.00	25.00	2		2		2							
H4754	008	0	1	04	01	H4754_008_0	8	11	Outpatient Hospital	01	0000000000000000000010000000000000000		2		1	350.00	350.00	2		2		1		20		20			
H4754	009	0	1	04	01	H4754_009_0	7	1	20% coinsurance	11	0111010110110110000000110001111111001	000000000000000100000010	2		2			2		2		1		20		20			
H4754	009	0	1	04	01	H4754_009_0	7	10	Routine eyewear	10		000000000000000000000100	1	100.00	2			2		2		2							
H4754	009	0	1	04	01	H4754_009_0	7	11	Outpatient Hospital	01	0000000000000000000010000000000000000		2		1	350.00	350.00	2		2		1		20		20			
H4754	009	0	1	04	01	H4754_009_0	7	2	PCP Copay	01	0000001000000000000000000000000000000		2		1	25.00	25.00	2		2		2							
H4754	009	0	1	04	01	H4754_009_0	7	3	Specialist Copay	01	0000100001000000000000000000000000000		2		1	45.00	45.00	2		2		2							
H4754	009	0	1	04	01	H4754_009_0	7	9	Other health care professional	01	0000000000001000000000000000000000000		2		1	25.00	45.00	2		2		2							
H4754	009	0	1	04	01	H4754_009_0	7	5	$0 copay	11	0000000000000000000000000000000000010	000000000000000010000000	2		2			2		2		2							
H4754	009	0	1	04	01	H4754_009_0	7	6	ASC	01	0000000000000000000001000000000000000		2		1	350.00	350.00	2		2		2							
H4754	009	0	1	04	01	H4754_009_0	7	7	Office visit copay	11	0000000000000001111100000000000000100	000000000000000000001000	2		2			2		1	2	1		20		20	1	25.00	45.00
H4754	009	0	1	04	01	H4754_009_0	7	8	Ambulance	01	0000000000000000000000001000000000000		2		1	155.00	155.00	2		2		2							
H4754	009	0	1	04	01	H4754_009_0	7	4	20-30% coinsurance	01	0000000000000000000000000110000000000		2		2			2		2		1		20		30			
H4754	010	0	1	04	01	H4754_010_0	8	4	20-30% coinsurance	01	0000000000000000000000000110000000000		2		2			2		2		1		20		30			
H4754	010	0	1	04	01	H4754_010_0	8	5	$0 copay	11	0000000000000000000000000000000000010	000000000000000010000000	2		2			2		2		2							
H4754	010	0	1	04	01	H4754_010_0	8	6	ASC	01	0000000000000000000001000000000000000		2		1	350.00	350.00	2		2		2							
H4754	010	0	1	04	01	H4754_010_0	8	7	Office visit copay	11	0000000000000001111100000000000000100	000000000000000000001000	2		2			2		1	2	1		20		20	1	25.00	45.00
H4754	010	0	1	04	01	H4754_010_0	8	8	Ambulance	01	0000000000000000000000001000000000000		2		1	155.00	155.00	2		2		2							
H4754	010	0	1	04	01	H4754_010_0	8	9	Other health care professional	01	0000000000001000000000000000000000000		2		1	25.00	45.00	2		2		2							
H4754	010	0	1	04	01	H4754_010_0	8	1	20% coinsurance	11	0111010110110110000000110001111111001	000000000000000100000010	2		2			2		2		1		20		20			
H4754	010	0	1	04	01	H4754_010_0	8	10	Routine eyewear	10		000000000000000000000100	1	100.00	2			2		2		2							
H4754	010	0	1	04	01	H4754_010_0	8	11	Outpatient Hospital	01	0000000000000000000010000000000000000		2		1	350.00	350.00	2		2		1		20		20			
H4754	010	0	1	04	01	H4754_010_0	8	2	PCP Copay	01	0000001000000000000000000000000000000		2		1	25.00	25.00	2		2		2							
H4754	010	0	1	04	01	H4754_010_0	8	3	Specialist Copay	01	0000100001000000000000000000000000000		2		1	45.00	45.00	2		2		2							
H4754	011	0	1	04	01	H4754_011_0	7	1	20% coinsurance	11	0111010110110110000000110001111111001	000000000000000100000010	2		2			2		2		1		20		20			
H4754	011	0	1	04	01	H4754_011_0	7	10	Routine eyewear	10		000000000000000000000100	1	100.00	2			2		2		2							
H4754	011	0	1	04	01	H4754_011_0	7	11	Outpatient Hospital	01	0000000000000000000010000000000000000		2		1	350.00	350.00	2		2		1		20		20			
H4754	011	0	1	04	01	H4754_011_0	7	2	PCP Copay	01	0000001000000000000000000000000000000		2		1	25.00	25.00	2		2		2							
H4754	011	0	1	04	01	H4754_011_0	7	3	Specialist Copay	01	0000100001000000000000000000000000000		2		1	45.00	45.00	2		2		2							
H4754	011	0	1	04	01	H4754_011_0	7	9	Other health care professional	01	0000000000001000000000000000000000000		2		1	25.00	45.00	2		2		2							
H4754	011	0	1	04	01	H4754_011_0	7	5	$0 copay	11	0000000000000000000000000000000000010	000000000000000010000000	2		2			2		2		2							
H4754	011	0	1	04	01	H4754_011_0	7	6	ASC	01	0000000000000000000001000000000000000		2		1	350.00	350.00	2		2		2							
H4754	011	0	1	04	01	H4754_011_0	7	7	Office visit copay	11	0000000000000001111100000000000000100	000000000000000000001000	2		2			2		1	2	1		20		20	1	25.00	45.00
H4754	011	0	1	04	01	H4754_011_0	7	8	Ambulance	01	0000000000000000000000001000000000000		2		1	155.00	155.00	2		2		2							
H4754	011	0	1	04	01	H4754_011_0	7	4	20-30% coinsurance	01	0000000000000000000000000110000000000		2		2			2		2		1		20		30			
H4754	012	0	1	04	01	H4754_012_0	8	1	20% coinsurance	11	0111010110110110000000110001111111001	000000000000000100000010	2		2			2		2		1		20		20			
H4754	012	0	1	04	01	H4754_012_0	8	10	Routine eyewear	10		000000000000000000000100	1	100.00	2			2		2		2							
H4754	012	0	1	04	01	H4754_012_0	8	9	Other health care professional	01	0000000000001000000000000000000000000		2		1	25.00	45.00	2		2		2							
H4754	012	0	1	04	01	H4754_012_0	8	8	Ambulance	01	0000000000000000000000001000000000000		2		1	155.00	155.00	2		2		2							
H4754	012	0	1	04	01	H4754_012_0	8	7	Office visit copay	11	0000000000000001111100000000000000100	000000000000000000001000	2		2			2		1	2	1		20		20	1	25.00	45.00
H4754	012	0	1	04	01	H4754_012_0	8	11	Outpatient Hospital	01	0000000000000000000010000000000000000		2		1	350.00	350.00	2		2		1		20		20			
H4754	012	0	1	04	01	H4754_012_0	8	2	PCP Copay	01	0000001000000000000000000000000000000		2		1	25.00	25.00	2		2		2							
H4754	012	0	1	04	01	H4754_012_0	8	3	Specialist Copay	01	0000100001000000000000000000000000000		2		1	45.00	45.00	2		2		2							
H4754	012	0	1	04	01	H4754_012_0	8	4	20-30% coinsurance	01	0000000000000000000000000110000000000		2		2			2		2		1		20		30			
H4754	012	0	1	04	01	H4754_012_0	8	5	$0 copay	11	0000000000000000000000000000000000010	000000000000000010000000	2		2			2		2		2							
H4754	012	0	1	04	01	H4754_012_0	8	6	ASC	01	0000000000000000000001000000000000000		2		1	350.00	350.00	2		2		2							
H4754	801	0	1	04	01	H4754_801_0	5	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4754	801	0	1	04	01	H4754_801_0	5	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4754	802	0	1	04	01	H4754_802_0	5	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4754	802	0	1	04	01	H4754_802_0	5	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4875	016	1	1	04	01	H4875_016_1	7	3	30% coinsurance	01	0000000000000000000000000110000000000		2		2			2		2		1		30		30			
H4875	016	1	1	04	01	H4875_016_1	7	2	25% coinsurance (+ physician coins.)	01	0000000000000001111100000000000100000		2		2			2		1	1	1	25	25	25	25	2		
H4875	016	1	1	04	01	H4875_016_1	7	8	0-50% Coinsurance	10		000000000000000000100000	2		2			2		2		1		0		50			
H4875	016	1	1	04	01	H4875_016_1	7	7	40% coinsurance	01	0000100000000000000000000000000000000		2		2			2		2		1		40		40			
H4875	016	1	1	04	01	H4875_016_1	7	6	$0 copayment	11	0000010000000000000000010000000000000	000000100000000010000000	2		2			2		2		2							
H4875	016	1	1	04	01	H4875_016_1	7	5	$150 copayment	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H4875	016	1	1	04	01	H4875_016_1	7	4	0-20% coinsurance	11	0000000000000000000000000000000010000	000000000000000001000000	2		2			2		2		1		0		20			
H4875	016	1	1	04	01	H4875_016_1	7	1	25% coinsurance	11	0111001111111110000011100001111001111	000000000000000100000000	2		2			2		2		1		25		25			
H4875	016	2	1	04	01	H4875_016_2	5	1	25% coinsurance	11	0111001111111110000011100001111001111	000000000000000100000000	2		2			2		2		1		25		25			
H4875	016	2	1	04	01	H4875_016_2	5	7	40% coinsurance	01	0000100000000000000000000000000000000		2		2			2		2		1		40		40			
H4875	016	2	1	04	01	H4875_016_2	5	6	$0 copayment	11	0000010000000000000000010000000000000	000000100000000010000000	2		2			2		2		2							
H4875	016	2	1	04	01	H4875_016_2	5	5	$150 copayment	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H4875	016	2	1	04	01	H4875_016_2	5	4	0-20% coinsurance	11	0000000000000000000000000000000010000	000000000000000001000000	2		2			2		2		1		0		20			
H4875	016	2	1	04	01	H4875_016_2	5	3	30% coinsurance	01	0000000000000000000000000110000000000		2		2			2		2		1		30		30			
H4875	016	2	1	04	01	H4875_016_2	5	2	25% coinsurance (+ physician coins.)	01	0000000000000001111100000000000100000		2		2			2		1	1	1	25	25	25	25	2		
H4875	016	2	1	04	01	H4875_016_2	5	8	0-50% Coinsurance	10		000000000000000000100000	2		2			2		2		1		0		50			
H4875	016	3	1	04	01	H4875_016_3	5	3	30% coinsurance	01	0000000000000000000000000110000000000		2		2			2		2		1		30		30			
H4875	016	3	1	04	01	H4875_016_3	5	2	25% coinsurance (+ physician coins.)	01	0000000000000001111100000000000100000		2		2			2		1	1	1	25	25	25	25	2		
H4875	016	3	1	04	01	H4875_016_3	5	1	25% coinsurance	11	0111001111111110000011100001111001111	000000000000000100000000	2		2			2		2		1		25		25			
H4875	016	3	1	04	01	H4875_016_3	5	4	0-20% coinsurance	11	0000000000000000000000000000000010000	000000000000000001000000	2		2			2		2		1		0		20			
H4875	016	3	1	04	01	H4875_016_3	5	8	0-50% Coinsurance	10		000000000000000000100000	2		2			2		2		1		0		50			
H4875	016	3	1	04	01	H4875_016_3	5	7	40% coinsurance	01	0000100000000000000000000000000000000		2		2			2		2		1		40		40			
H4875	016	3	1	04	01	H4875_016_3	5	6	$0 copayment	11	0000010000000000000000010000000000000	000000100000000010000000	2		2			2		2		2							
H4875	016	3	1	04	01	H4875_016_3	5	5	$150 copayment	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H4875	016	4	1	04	01	H4875_016_4	5	1	25% coinsurance	11	0111001111111110000011100001111001111	000000000000000100000000	2		2			2		2		1		25		25			
H4875	016	4	1	04	01	H4875_016_4	5	2	25% coinsurance (+ physician coins.)	01	0000000000000001111100000000000100000		2		2			2		1	1	1	25	25	25	25	2		
H4875	016	4	1	04	01	H4875_016_4	5	8	0-50% Coinsurance	10		000000000000000000100000	2		2			2		2		1		0		50			
H4875	016	4	1	04	01	H4875_016_4	5	7	40% coinsurance	01	0000100000000000000000000000000000000		2		2			2		2		1		40		40			
H4875	016	4	1	04	01	H4875_016_4	5	6	$0 copayment	11	0000010000000000000000010000000000000	000000100000000010000000	2		2			2		2		2							
H4875	016	4	1	04	01	H4875_016_4	5	5	$150 copayment	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H4875	016	4	1	04	01	H4875_016_4	5	4	0-20% coinsurance	11	0000000000000000000000000000000010000	000000000000000001000000	2		2			2		2		1		0		20			
H4875	016	4	1	04	01	H4875_016_4	5	3	30% coinsurance	01	0000000000000000000000000110000000000		2		2			2		2		1		30		30			
H4875	016	5	1	04	01	H4875_016_5	5	1	25% coinsurance	11	0111001111111110000011100001111001111	000000000000000100000000	2		2			2		2		1		25		25			
H4875	016	5	1	04	01	H4875_016_5	5	4	0-20% coinsurance	11	0000000000000000000000000000000010000	000000000000000001000000	2		2			2		2		1		0		20			
H4875	016	5	1	04	01	H4875_016_5	5	5	$150 copayment	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H4875	016	5	1	04	01	H4875_016_5	5	6	$0 copayment	11	0000010000000000000000010000000000000	000000100000000010000000	2		2			2		2		2							
H4875	016	5	1	04	01	H4875_016_5	5	7	40% coinsurance	01	0000100000000000000000000000000000000		2		2			2		2		1		40		40			
H4875	016	5	1	04	01	H4875_016_5	5	3	30% coinsurance	01	0000000000000000000000000110000000000		2		2			2		2		1		30		30			
H4875	016	5	1	04	01	H4875_016_5	5	2	25% coinsurance (+ physician coins.)	01	0000000000000001111100000000000100000		2		2			2		1	1	1	25	25	25	25	2		
H4875	016	5	1	04	01	H4875_016_5	5	8	0-50% Coinsurance	10		000000000000000000100000	2		2			2		2		1		0		50			
H4875	017	1	1	04	01	H4875_017_1	7	3	30% coinsurance	01	0000000000000000000000000110000000000		2		2			2		2		1		30		30			
H4875	017	1	1	04	01	H4875_017_1	7	2	20% coinsurance (+ physician coins)	01	0000000000000001111100000000000100000		2		2			2		1	1	1	20	20	20	20	2		
H4875	017	1	1	04	01	H4875_017_1	7	8	0-50% Coinsurance	10		000000000000000000100000	2		2			2		2		1		0		50			
H4875	017	1	1	04	01	H4875_017_1	7	7	40% coinsurance	01	0000100000000000000000000000000000000		2		2			2		2		1		40		40			
H4875	017	1	1	04	01	H4875_017_1	7	6	$0 copayment	11	0000010000000000000000010000000000000	000000100000000010000000	2		2			2		2		2							
H4875	017	1	1	04	01	H4875_017_1	7	5	$100 copayment	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H4875	017	1	1	04	01	H4875_017_1	7	4	0%-20% coinsurance	11	0000000000000000000000000000000010000	000000000000000001000000	2		2			2		2		1		0		20			
H4875	017	1	1	04	01	H4875_017_1	7	1	20% coinsurance	11	0111001111111110000011100001111001111	000000000000000100000000	2		2			2		2		1		20		20			
H4875	017	2	1	04	01	H4875_017_2	5	1	20% coinsurance	11	0111001111111110000011100001111001111	000000000000000100000000	2		2			2		2		1		20		20			
H4875	017	2	1	04	01	H4875_017_2	5	7	40% coinsurance	01	0000100000000000000000000000000000000		2		2			2		2		1		40		40			
H4875	017	2	1	04	01	H4875_017_2	5	6	$0 copayment	11	0000010000000000000000010000000000000	000000100000000010000000	2		2			2		2		2							
H4875	017	2	1	04	01	H4875_017_2	5	5	$100 copayment	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H4875	017	2	1	04	01	H4875_017_2	5	4	0%-20% coinsurance	11	0000000000000000000000000000000010000	000000000000000001000000	2		2			2		2		1		0		20			
H4875	017	2	1	04	01	H4875_017_2	5	3	30% coinsurance	01	0000000000000000000000000110000000000		2		2			2		2		1		30		30			
H4875	017	2	1	04	01	H4875_017_2	5	2	20% coinsurance (+ physician coins)	01	0000000000000001111100000000000100000		2		2			2		1	1	1	20	20	20	20	2		
H4875	017	2	1	04	01	H4875_017_2	5	8	0-50% Coinsurance	10		000000000000000000100000	2		2			2		2		1		0		50			
H4875	017	3	1	04	01	H4875_017_3	5	3	30% coinsurance	01	0000000000000000000000000110000000000		2		2			2		2		1		30		30			
H4875	017	3	1	04	01	H4875_017_3	5	2	20% coinsurance (+ physician coins)	01	0000000000000001111100000000000100000		2		2			2		1	1	1	20	20	20	20	2		
H4875	017	3	1	04	01	H4875_017_3	5	1	20% coinsurance	11	0111001111111110000011100001111001111	000000000000000100000000	2		2			2		2		1		20		20			
H4875	017	3	1	04	01	H4875_017_3	5	4	0%-20% coinsurance	11	0000000000000000000000000000000010000	000000000000000001000000	2		2			2		2		1		0		20			
H4875	017	3	1	04	01	H4875_017_3	5	8	0-50% Coinsurance	10		000000000000000000100000	2		2			2		2		1		0		50			
H4875	017	3	1	04	01	H4875_017_3	5	7	40% coinsurance	01	0000100000000000000000000000000000000		2		2			2		2		1		40		40			
H4875	017	3	1	04	01	H4875_017_3	5	6	$0 copayment	11	0000010000000000000000010000000000000	000000100000000010000000	2		2			2		2		2							
H4875	017	3	1	04	01	H4875_017_3	5	5	$100 copayment	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H4875	017	4	1	04	01	H4875_017_4	5	1	20% coinsurance	11	0111001111111110000011100001111001111	000000000000000100000000	2		2			2		2		1		20		20			
H4875	017	4	1	04	01	H4875_017_4	5	2	20% coinsurance (+ physician coins)	01	0000000000000001111100000000000100000		2		2			2		1	1	1	20	20	20	20	2		
H4875	017	4	1	04	01	H4875_017_4	5	8	0-50% Coinsurance	10		000000000000000000100000	2		2			2		2		1		0		50			
H4875	017	4	1	04	01	H4875_017_4	5	7	40% coinsurance	01	0000100000000000000000000000000000000		2		2			2		2		1		40		40			
H4875	017	4	1	04	01	H4875_017_4	5	6	$0 copayment	11	0000010000000000000000010000000000000	000000100000000010000000	2		2			2		2		2							
H4875	017	4	1	04	01	H4875_017_4	5	5	$100 copayment	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H4875	017	4	1	04	01	H4875_017_4	5	4	0%-20% coinsurance	11	0000000000000000000000000000000010000	000000000000000001000000	2		2			2		2		1		0		20			
H4875	017	4	1	04	01	H4875_017_4	5	3	30% coinsurance	01	0000000000000000000000000110000000000		2		2			2		2		1		30		30			
H4875	017	5	1	04	01	H4875_017_5	5	1	20% coinsurance	11	0111001111111110000011100001111001111	000000000000000100000000	2		2			2		2		1		20		20			
H4875	017	5	1	04	01	H4875_017_5	5	4	0%-20% coinsurance	11	0000000000000000000000000000000010000	000000000000000001000000	2		2			2		2		1		0		20			
H4875	017	5	1	04	01	H4875_017_5	5	5	$100 copayment	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H4875	017	5	1	04	01	H4875_017_5	5	6	$0 copayment	11	0000010000000000000000010000000000000	000000100000000010000000	2		2			2		2		2							
H4875	017	5	1	04	01	H4875_017_5	5	7	40% coinsurance	01	0000100000000000000000000000000000000		2		2			2		2		1		40		40			
H4875	017	5	1	04	01	H4875_017_5	5	3	30% coinsurance	01	0000000000000000000000000110000000000		2		2			2		2		1		30		30			
H4875	017	5	1	04	01	H4875_017_5	5	2	20% coinsurance (+ physician coins)	01	0000000000000001111100000000000100000		2		2			2		1	1	1	20	20	20	20	2		
H4875	017	5	1	04	01	H4875_017_5	5	8	0-50% Coinsurance	10		000000000000000000100000	2		2			2		2		1		0		50			
H4875	018	1	1	04	01	H4875_018_1	7	5	$150 copayment	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H4875	018	1	1	04	01	H4875_018_1	7	4	0%-20% coinsurance	11	0000000000000000000000000000000010000	000000000000000001000000	2		2			2		2		1		0		20			
H4875	018	1	1	04	01	H4875_018_1	7	3	30% coinsurance	01	0000000000000000000000000110000000000		2		2			2		2		1		30		30			
H4875	018	1	1	04	01	H4875_018_1	7	2	40% coinsurance (+ physician coins)	01	0000000000000001111100000000000100000		2		2			2		1	1	1	40	40	40	40	2		
H4875	018	1	1	04	01	H4875_018_1	7	1	40% coinsurance	11	0111101111111110000011100001111001111	000000000000000100000000	2		2			2		2		1		40		40			
H4875	018	1	1	04	01	H4875_018_1	7	6	$0 copayment	11	0000010000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H4875	018	2	1	04	01	H4875_018_2	6	5	$150 copayment	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H4875	018	2	1	04	01	H4875_018_2	6	4	0%-20% coinsurance	11	0000000000000000000000000000000010000	000000000000000001000000	2		2			2		2		1		0		20			
H4875	018	2	1	04	01	H4875_018_2	6	3	30% coinsurance	01	0000000000000000000000000110000000000		2		2			2		2		1		30		30			
H4875	018	2	1	04	01	H4875_018_2	6	2	40% coinsurance (+ physician coins)	01	0000000000000001111100000000000100000		2		2			2		1	1	1	40	40	40	40	2		
H4875	018	2	1	04	01	H4875_018_2	6	1	40% coinsurance	11	0111101111111110000011100001111001111	000000000000000100000000	2		2			2		2		1		40		40			
H4875	018	2	1	04	01	H4875_018_2	6	6	$0 copayment	11	0000010000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H4875	018	3	1	04	01	H4875_018_3	6	1	40% coinsurance	11	0111101111111110000011100001111001111	000000000000000100000000	2		2			2		2		1		40		40			
H4875	018	3	1	04	01	H4875_018_3	6	2	40% coinsurance (+ physician coins)	01	0000000000000001111100000000000100000		2		2			2		1	1	1	40	40	40	40	2		
H4875	018	3	1	04	01	H4875_018_3	6	3	30% coinsurance	01	0000000000000000000000000110000000000		2		2			2		2		1		30		30			
H4875	018	3	1	04	01	H4875_018_3	6	4	0%-20% coinsurance	11	0000000000000000000000000000000010000	000000000000000001000000	2		2			2		2		1		0		20			
H4875	018	3	1	04	01	H4875_018_3	6	5	$150 copayment	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H4875	018	3	1	04	01	H4875_018_3	6	6	$0 copayment	11	0000010000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H4875	018	4	1	04	01	H4875_018_4	6	1	40% coinsurance	11	0111101111111110000011100001111001111	000000000000000100000000	2		2			2		2		1		40		40			
H4875	018	4	1	04	01	H4875_018_4	6	2	40% coinsurance (+ physician coins)	01	0000000000000001111100000000000100000		2		2			2		1	1	1	40	40	40	40	2		
H4875	018	4	1	04	01	H4875_018_4	6	3	30% coinsurance	01	0000000000000000000000000110000000000		2		2			2		2		1		30		30			
H4875	018	4	1	04	01	H4875_018_4	6	4	0%-20% coinsurance	11	0000000000000000000000000000000010000	000000000000000001000000	2		2			2		2		1		0		20			
H4875	018	4	1	04	01	H4875_018_4	6	5	$150 copayment	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H4875	018	4	1	04	01	H4875_018_4	6	6	$0 copayment	11	0000010000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H4875	018	5	1	04	01	H4875_018_5	6	1	40% coinsurance	11	0111101111111110000011100001111001111	000000000000000100000000	2		2			2		2		1		40		40			
H4875	018	5	1	04	01	H4875_018_5	6	2	40% coinsurance (+ physician coins)	01	0000000000000001111100000000000100000		2		2			2		1	1	1	40	40	40	40	2		
H4875	018	5	1	04	01	H4875_018_5	6	3	30% coinsurance	01	0000000000000000000000000110000000000		2		2			2		2		1		30		30			
H4875	018	5	1	04	01	H4875_018_5	6	4	0%-20% coinsurance	11	0000000000000000000000000000000010000	000000000000000001000000	2		2			2		2		1		0		20			
H4875	018	5	1	04	01	H4875_018_5	6	5	$150 copayment	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H4875	018	5	1	04	01	H4875_018_5	6	6	$0 copayment	11	0000010000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H4875	803	0	1	04	01	H4875_803_0	4	1	20% Coinsurance	11	0111111111111110000011111111111011011	000000000000000100000000	2		2			2		2		1		20		20			
H4875	803	0	1	04	01	H4875_803_0	4	2	20% Coinsurance (+ physician coins)	01	0000000000000001111100000000000100100		2		2			2		1	1	1	20	20	20	20	2		
H4875	804	0	1	04	01	H4875_804_0	4	1	20% Coinsurance	11	0111111111111110000011111111111011011	000000000000000100000000	2		2			2		2		1		20		20			
H4875	804	0	1	04	01	H4875_804_0	4	2	20% Coinsurance (+ physician coins)	01	0000000000000001111100000000000100100		2		2			2		1	1	1	20	20	20	20	2		
H4876	001	0	1	04	01	H4876_001_0	8	1		11	0111111111111111111111111111111111111	000000010000000000111100	2		2			2		2		1		20		20			
H4876	001	0	1	04	01	H4876_001_0	8	2		10		000000000100000000000000	1	20.00	2			2		2		2							
H4876	801	0	1	04	01	H4876_801_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4876	801	0	1	04	01	H4876_801_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4876	802	0	1	04	01	H4876_802_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4876	802	0	1	04	01	H4876_802_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4909	014	0	1	04	01	H4909_014_0	14	1	$0-50%	10		000000000000000010000000	2		1	0.00	0.00	2		2		1		50		50			
H4909	014	0	1	04	01	H4909_014_0	14	10	$150 copay	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H4909	014	0	1	04	01	H4909_014_0	14	9	30% coinsurance	01	0000000000000000000001000111000000000		2		2			2		2		1		30		30			
H4909	014	0	1	04	01	H4909_014_0	14	8	30%, $30-$50	01	0000000000000000000010000000000000000		2		1	30.00	50.00	2		2		1		30		30			
H4909	014	0	1	04	01	H4909_014_0	14	7	20% coinsurance	11	0000000000000000001000000000100000000	000000000000000000100000	2		2			2		2		1		20		20			
H4909	014	0	1	04	01	H4909_014_0	14	6	$35 copay	01	0000000000000000100000000000000000000		2		1	35.00	35.00	2		2		2							
H4909	014	0	1	04	01	H4909_014_0	14	5	$150 -$225 copay	01	0000000000000001000100000000000000000		2		1	150.00	225.00	2		2		2							
H4909	014	0	1	04	01	H4909_014_0	14	11	$0-$50	01	0000000000000000000000000000010000000		2		1	0.00	50.00	2		2		2							
H4909	014	0	1	04	01	H4909_014_0	14	12	25% coinsurance	01	0000000000000000000000000000000010000		2		2			2		2		1		25		25			
H4909	014	0	1	04	01	H4909_014_0	14	13	$0-$50	01	0000000000000000000000000000000000100		2		1	0.00	50.00	2		2		2							
H4909	014	0	1	04	01	H4909_014_0	14	14	$0	10		000000000000000000001000	1	69.00	1	0.00	0.00	2		2		2							
H4909	014	0	1	04	01	H4909_014_0	14	15	$200-$225	01	0000000000000000010000000000000000000		2		1	200.00	225.00	2		1	2	2					1	30.00	50.00
H4909	014	0	1	04	01	H4909_014_0	14	2	$50 copay	01	0111100111110110000000100000000000011		2		1	50.00	50.00	2		2		2							
H4909	014	0	1	04	01	H4909_014_0	14	3	$0 copay	11	0000010000000000000000010000001101000	000000100000000000000000	2		1	0.00	0.00	2		2		2							
H4909	014	0	1	04	01	H4909_014_0	14	4	$30 copay	11	0000001000001000000000000000000000000	000000000000000100000000	2		1	30.00	30.00	2		2		2							
H4909	804	0	1	04	01	H4909_804_0	6	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4909	804	0	1	04	01	H4909_804_0	6	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4909	805	0	1	04	01	H4909_805_0	6	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H4909	805	0	1	04	01	H4909_805_0	6	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4909	806	0	1	04	01	H4909_806_0	6	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H4909	806	0	1	04	01	H4909_806_0	6	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5009	001	0	1	04	01	H5009_001_0	8	11	20% coinsurance	01	0000010000000000000100000000000010000		2		2			2		2		1		20		20			
H5009	001	0	1	04	01	H5009_001_0	8	12	30% coinsurance	01	0000000000000000011000000110000000000		2		2			2		2		1		30		30			
H5009	001	0	1	04	01	H5009_001_0	8	2	$50 copay	01	0111000011101110000000100000000001101		2		1	50.00	50.00	2		2		2							
H5009	001	0	1	04	01	H5009_001_0	8	3	Dental Preventive Services $500 maximum	10		000000000000000000100000	1	500.00	2			2		2		1		50		50			
H5009	001	0	1	04	01	H5009_001_0	8	4	0 - Zero cost share	11	0000100000000001100000010001011100010	000000100000000110000000	2		2			2		2		2							
H5009	001	0	1	04	01	H5009_001_0	8	5	$0 to $350 copay	01	0000000000000000000010000000000000000		2		1	0.00	350.00	2		2		2							
H5009	001	0	1	04	01	H5009_001_0	8	6	$0 to $200 copay	01	0000000000000000000001000000000000000		2		1	0.00	200.00	2		2		2							
H5009	001	0	1	04	01	H5009_001_0	8	7	$40 copay VSP exam	10		000000000000000000001000	2		1	40.00	40.00	2		2		2							
H5009	001	0	1	04	01	H5009_001_0	8	8	VSP Eyewear $100 Maximum	10		000000000000000000000100	1	100.00	2			2		2		2							
H5009	001	0	1	04	01	H5009_001_0	8	9	$200 copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H5009	001	0	1	04	01	H5009_001_0	8	1	$25 copay	01	0000001100010000000000000000000000000		2		1	25.00	25.00	2		2		2							
H5009	001	0	1	04	01	H5009_001_0	8	10	10% coinsurance	01	0000000000000000000000000000100000000		2		2			2		2		1		10		10			
H5009	002	0	1	04	01	H5009_002_0	9	1	$25 copay	01	0000001100010000000000000000000000000		2		1	25.00	25.00	2		2		2							
H5009	002	0	1	04	01	H5009_002_0	9	10	10% coinsurance	01	0000000000000000000000000000100000000		2		2			2		2		1		10		10			
H5009	002	0	1	04	01	H5009_002_0	9	9	$200 copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H5009	002	0	1	04	01	H5009_002_0	9	8	VSP Eyewear $100 Maximum	10		000000000000000000000100	1	100.00	2			2		2		2							
H5009	002	0	1	04	01	H5009_002_0	9	7	$40 copay VSP exam	10		000000000000000000001000	2		1	40.00	40.00	2		2		2							
H5009	002	0	1	04	01	H5009_002_0	9	11	20% coinsurance	11	0000010000000000000100000000000010000	000000000000000001000000	2		2			2		2		1		20		20			
H5009	002	0	1	04	01	H5009_002_0	9	12	30% coinsurance	01	0000000000000000011000000110000000000		2		2			2		2		1		30		30			
H5009	002	0	1	04	01	H5009_002_0	9	2	$50 copay	01	0111000011101110000000100000000001101		2		1	50.00	50.00	2		2		2							
H5009	002	0	1	04	01	H5009_002_0	9	3	Dental Preventive Services $500 maximum	10		000000000000000000100000	1	500.00	2			2		2		1		50		50			
H5009	002	0	1	04	01	H5009_002_0	9	4	0 - Zero cost share	11	0000100000000001100000010001011100010	000000100000000110000000	2		2			2		2		2							
H5009	002	0	1	04	01	H5009_002_0	9	5	$0 to $350 copay	01	0000000000000000000010000000000000000		2		1	0.00	350.00	2		2		2							
H5009	002	0	1	04	01	H5009_002_0	9	6	$0 to $200 copay	01	0000000000000000000001000000000000000		2		1	0.00	200.00	2		2		2							
H5009	801	0	1	04	01	H5009_801_0	8	2	20% coinsurance	01	0111101111111111011111111111101111111		2		2			2		2		1		20		20			
H5009	801	0	1	04	01	H5009_801_0	8	1	$0 copay	01	0000010000000000100000000000010000000		2		2			2		2		2							
H5009	802	0	1	04	01	H5009_802_0	8	1	$0 copay	01	0000010000000000100000000000010000000		2		2			2		2		2							
H5009	802	0	1	04	01	H5009_802_0	8	2	20% coinsurance	01	0111101111111111011111111111101111111		2		2			2		2		1		20		20			
H5010	001	0	1	04	01	H5010_001_0	8	4	0 - Zero cost share	11	0000100000000001100000010001011100010	000000100000000110000000	2		2			2		2		2							
H5010	001	0	1	04	01	H5010_001_0	8	3	Dental Preventive Services $500 maximum	10		000000000000000000100000	1	500.00	2			2		2		1		50		50			
H5010	001	0	1	04	01	H5010_001_0	8	2	$50 copay	01	0111000011101110000000100000000001101		2		1	50.00	50.00	2		2		2							
H5010	001	0	1	04	01	H5010_001_0	8	11	20% coinsurance	01	0000010000000000000100000000100010000		2		2			2		2		1		20		20			
H5010	001	0	1	04	01	H5010_001_0	8	10	30% coinsurance	01	0000000000000000011000000110000000000		2		2			2		2		1		30		30			
H5010	001	0	1	04	01	H5010_001_0	8	9	$200 copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H5010	001	0	1	04	01	H5010_001_0	8	5	$0 to $350 copay	01	0000000000000000000010000000000000000		2		1	0.00	350.00	2		2		2							
H5010	001	0	1	04	01	H5010_001_0	8	6	$0 to $200 copay	01	0000000000000000000001000000000000000		2		1	0.00	200.00	2		2		2							
H5010	001	0	1	04	01	H5010_001_0	8	7	$40 copay VSP exam	10		000000000000000000001000	2		1	40.00	40.00	2		2		2							
H5010	001	0	1	04	01	H5010_001_0	8	8	VSP Eyewear $100 Maximum	10		000000000000000000000100	1	100.00	2			2		2		2							
H5010	001	0	1	04	01	H5010_001_0	8	1	$25 copay	01	0000001100010000000000000000000000000		2		1	25.00	25.00	2		2		2							
H5010	002	0	1	04	01	H5010_002_0	9	4	0 - Zero cost share	11	0000100000000001100000010001011100010	000000100000000110000000	2		2			2		2		2							
H5010	002	0	1	04	01	H5010_002_0	9	3	Dental Preventive Services $500 maximum	10		000000000000000000100000	1	500.00	2			2		2		1		50		50			
H5010	002	0	1	04	01	H5010_002_0	9	2	$50 copay	01	0111000011101110000000100000000001101		2		1	50.00	50.00	2		2		2							
H5010	002	0	1	04	01	H5010_002_0	9	11	20% coinsurance	11	0000010000000000000100000000100010000	000000000000000001000000	2		2			2		2		1		20		20			
H5010	002	0	1	04	01	H5010_002_0	9	10	30% coinsurance	01	0000000000000000011000000110000000000		2		2			2		2		1		30		30			
H5010	002	0	1	04	01	H5010_002_0	9	1	$25 copay	01	0000001100010000000000000000000000000		2		1	25.00	25.00	2		2		2							
H5010	002	0	1	04	01	H5010_002_0	9	5	$0 to $350 copay	01	0000000000000000000010000000000000000		2		1	0.00	350.00	2		2		2							
H5010	002	0	1	04	01	H5010_002_0	9	9	$200 copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H5010	002	0	1	04	01	H5010_002_0	9	8	VSP Eyewear $100 Maximum	10		000000000000000000000100	1	100.00	2			2		2		2							
H5010	002	0	1	04	01	H5010_002_0	9	7	$40 copay VSP exam	10		000000000000000000001000	2		1	40.00	40.00	2		2		2							
H5010	002	0	1	04	01	H5010_002_0	9	6	$0 to $200 copay	01	0000000000000000000001000000000000000		2		1	0.00	200.00	2		2		2							
H5010	004	0	1	04	01	H5010_004_0	9	1	$20 copay	01	0000001100010000000000000000000000000		2		1	20.00	20.00	2		2		2							
H5010	004	0	1	04	01	H5010_004_0	9	10	10% coinsurance	11	0000010000000000000100000000000010000	000000000000000001000000	2		2			2		2		1		10		10			
H5010	004	0	1	04	01	H5010_004_0	9	11	20% coinsurance	01	0000000000000000000000000110100000000		2		2			2		2		1		20		20			
H5010	004	0	1	04	01	H5010_004_0	9	12	Hearing Aid - $500 maximum	10		000000000000000000000001	1	500.00	2			2		2		2							
H5010	004	0	1	04	01	H5010_004_0	9	13	30% coinsurance	01	0000000000000000011000000000000000000		2		2			2		2		1		30		30			
H5010	004	0	1	04	01	H5010_004_0	9	2	$40 copay	01	0111000011101110000000100000000001101		2		1	40.00	40.00	2		2		2							
H5010	004	0	1	04	01	H5010_004_0	9	9	$200 copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H5010	004	0	1	04	01	H5010_004_0	9	4	0 - Zero cost share	11	0000100000000001100000010001011100010	000000100000000110000000	2		2			2		2		2							
H5010	004	0	1	04	01	H5010_004_0	9	8	VSP Eyewear $200 Maximum	10		000000000000000000000100	1	200.00	2			2		2		2							
H5010	004	0	1	04	01	H5010_004_0	9	7	$30 copay VSP exam	10		000000000000000000001000	2		1	30.00	30.00	2		2		2							
H5010	004	0	1	04	01	H5010_004_0	9	6	$0 to $175 copay	01	0000000000000000000001000000000000000		2		1	0.00	175.00	2		2		2							
H5010	004	0	1	04	01	H5010_004_0	9	5	$0 to $300 copay	01	0000000000000000000010000000000000000		2		1	0.00	300.00	2		2		2							
H5010	004	0	1	04	01	H5010_004_0	9	3	Dental Preventive Services $500 maximum	10		000000000000000000100000	1	500.00	2			2		2		1		50		50			
H5042	001	0	1	04	01	H5042_001_0	8	1	$0 copayment	11	0001010000000000000000010000011101000	000100010000000010000000	2		1	0.00	0.00	2		2		2							
H5042	001	0	1	04	01	H5042_001_0	8	10	$60 copayment	01	0000000000000000011100000000000000000		2		1	60.00	60.00	2		2		2							
H5042	001	0	1	04	01	H5042_001_0	8	9	$55 copayment	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
H5042	001	0	1	04	01	H5042_001_0	8	8	$10 Copayment	11	0110000000000000000000000000000000000	001000000000000000000000	2		1	10.00	10.00	2		2		2							
H5042	001	0	1	04	01	H5042_001_0	8	7	20% coinsurance	01	0000000000000000000000000111000010010		2		2			2		2		1		20		20			
H5042	001	0	1	04	01	H5042_001_0	8	6	$0-$50 copayment	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	50.00	2		2		2							
H5042	001	0	1	04	01	H5042_001_0	8	5	$175 copayment	01	0000000000000000000001000000000000000		2		1	175.00	175.00	2		2		2							
H5042	001	0	1	04	01	H5042_001_0	8	4	$200 copayment	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H5042	001	0	1	04	01	H5042_001_0	8	3	$50 copayment	11	0000000001011001100000000000000000001	000000000000000000000010	2		1	50.00	50.00	2		2		2							
H5042	001	0	1	04	01	H5042_001_0	8	2	$40 copayment	01	0000001010100110000000100000000000000		2		1	40.00	40.00	2		2		2							
H5042	001	0	1	04	01	H5042_001_0	8	15	$225 copayment	01	0000000000000000000010000000000000000		2		1	225.00	225.00	2		2		2							
H5042	001	0	1	04	01	H5042_001_0	8	14	$0 copayment	10		000000000000000000000100	1	100.00	2			2		2		2							
H5042	001	0	1	04	01	H5042_001_0	8	13	$0 copayment	10		000000000000000000100000	1	250.00	2			2		2		2							
H5042	001	0	1	04	01	H5042_001_0	8	12	$30 copayment	01	0000000000000000000000000000100000000		2		1	30.00	30.00	2		2		2							
H5042	001	0	1	04	01	H5042_001_0	8	11	$20 copayment	01	0000000100000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H5042	004	0	1	04	01	H5042_004_0	5	1	$0 copayment	11	0001010000000000000000010000011101000	000100010000000010000000	2		1	0.00	0.00	2		2		2							
H5042	004	0	1	04	01	H5042_004_0	5	9	$55 copayment	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
H5042	004	0	1	04	01	H5042_004_0	5	7	20% coinsurance	01	0000000000000000000000000111000010010		2		2			2		2		1		20		20			
H5042	004	0	1	04	01	H5042_004_0	5	6	$0-$50 copayment	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	50.00	2		2		2							
H5042	004	0	1	04	01	H5042_004_0	5	5	$175 copayment	01	0000000000000000000001000000000000000		2		1	175.00	175.00	2		2		2							
H5042	004	0	1	04	01	H5042_004_0	5	4	$200 copayment	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H5042	004	0	1	04	01	H5042_004_0	5	3	$50 copayment	11	0000000001011001100000000000000000001	000000000000000000000010	2		1	50.00	50.00	2		2		2							
H5042	004	0	1	04	01	H5042_004_0	5	2	$40 copayment	01	0000001010100110000000100000000000000		2		1	40.00	40.00	2		2		2							
H5042	004	0	1	04	01	H5042_004_0	5	15	$225 copayment	01	0000000000000000000010000000000000000		2		1	225.00	225.00	2		2		2							
H5042	004	0	1	04	01	H5042_004_0	5	14	$0 copayment	10		000000000000000000000100	1	100.00	2			2		2		2							
H5042	004	0	1	04	01	H5042_004_0	5	13	$0 copayment	10		000000000000000000100000	1	250.00	2			2		2		2							
H5042	004	0	1	04	01	H5042_004_0	5	12	$30 copayment	01	0000000000000000000000000000100000000		2		1	30.00	30.00	2		2		2							
H5042	004	0	1	04	01	H5042_004_0	5	11	$20 copayment	01	0000000100000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H5042	004	0	1	04	01	H5042_004_0	5	10	$60 copayment	01	0000000000000000011100000000000000000		2		1	60.00	60.00	2		2		2							
H5042	004	0	1	04	01	H5042_004_0	5	8	$10 Copayment	11	0110000000000000000000000000000000000	001000000000000000000000	2		1	10.00	10.00	2		2		2							
H5042	005	0	1	04	01	H5042_005_0	7	1	$0 copayment	11	0001010000000000000000010000011101000	000100010000000010000000	2		1	0.00	0.00	2		2		2							
H5042	005	0	1	04	01	H5042_005_0	7	10	$20 Copayment	01	0000000100000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H5042	005	0	1	04	01	H5042_005_0	7	9	$55 Copayment	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
H5042	005	0	1	04	01	H5042_005_0	7	8	$30 Copayment	01	0000000000000000000000000000100000000		2		1	30.00	30.00	2		2		2							
H5042	005	0	1	04	01	H5042_005_0	7	7	20% coinsurance	01	0000000000000000000000000111000010010		2		2			2		2		1		20		20			
H5042	005	0	1	04	01	H5042_005_0	7	6	$0-$60 copayment	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	60.00	2		2		2							
H5042	005	0	1	04	01	H5042_005_0	7	5	$200 copayment	01	0000000000000000000001000000000000000		2		1	200.00	200.00	2		2		2							
H5042	005	0	1	04	01	H5042_005_0	7	4	$250 copayment	01	0000000000000000000010001000000000000		2		1	250.00	250.00	2		2		2							
H5042	005	0	1	04	01	H5042_005_0	7	3	$10 copayment	11	0110000000000000000000000000000000000	001000000000000000000000	2		1	10.00	10.00	2		2		2							
H5042	005	0	1	04	01	H5042_005_0	7	2	$40 copayment	01	0000000010100110000000100000000000000		2		1	40.00	40.00	2		2		2							
H5042	005	0	1	04	01	H5042_005_0	7	13	$0 copayment	10		000000000000000000100000	1	100.00	2			2		2		2							
H5042	005	0	1	04	01	H5042_005_0	7	12	$45 copayment	01	0000001000000000000000000000000000000		2		1	45.00	45.00	2		2		2							
H5042	005	0	1	04	01	H5042_005_0	7	11	$60 copayment	11	0000000001011001111100000000000000001	000000000000000000000010	2		1	60.00	60.00	2		2		2							
H5042	007	0	1	04	01	H5042_007_0	10	1	$0 copayment	11	0001010000000000000000010000011101000	000100010000000010000000	2		1	0.00	0.00	2		2		2							
H5042	007	0	1	04	01	H5042_007_0	10	10	$10 copayment	11	0110000000000000000000000000000000000	001000000000000000000000	2		1	10.00	10.00	2		2		2							
H5042	007	0	1	04	01	H5042_007_0	10	4	$200 copayment	01	0000000000000000000010001000000000000		2		1	200.00	200.00	2		2		2							
H5042	007	0	1	04	01	H5042_007_0	10	5	20% coinsurance	01	0000000000000000000000000111000010010		2		2			2		2		1		20		20			
H5042	007	0	1	04	01	H5042_007_0	10	6	$55 copayment	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
H5042	007	0	1	04	01	H5042_007_0	10	7	$20 copayment	01	0000000100000001100000000000000000000		2		1	20.00	20.00	2		2		2							
H5042	007	0	1	04	01	H5042_007_0	10	8	$150 copayment	01	0000000000000000000001000000000000000		2		1	150.00	150.00	2		2		2							
H5042	007	0	1	04	01	H5042_007_0	10	11	$0 copayment	10		000000000000000000100000	1	400.00	2			2		2		2							
H5042	007	0	1	04	01	H5042_007_0	10	12	$0 copayment	10		000000000000000000000100	1	150.00	2			2		2		2							
H5042	007	0	1	04	01	H5042_007_0	10	13	$60 copayment	01	0000000000000000011100000000000000000		2		1	60.00	60.00	2		2		2							
H5042	007	0	1	04	01	H5042_007_0	10	14	$35 copayment	01	0000001000000000000000000000000000000		2		1	35.00	35.00	2		2		2							
H5042	007	0	1	04	01	H5042_007_0	10	2	$40 copayment	11	0000000011111110000000100000000000001	000000000000000000000010	2		1	40.00	40.00	2		2		2							
H5042	007	0	1	04	01	H5042_007_0	10	3	$0-$40 copayment	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	40.00	2		2		2							
H5042	007	0	1	04	01	H5042_007_0	10	9	$30 copayment	01	0000000000000000000000000000100000000		2		1	30.00	30.00	2		2		2							
H5042	801	0	1	04	01	H5042_801_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5042	801	0	1	04	01	H5042_801_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5042	802	0	1	04	01	H5042_802_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5042	802	0	1	04	01	H5042_802_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5042	803	0	1	04	01	H5042_803_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5042	803	0	1	04	01	H5042_803_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5106	013	0	1	04	01	H5106_013_0	11	11	Hearing Aids	10		000000000000000000000001	1	500.00	2			2		2		2							
H5106	013	0	1	04	01	H5106_013_0	11	10	Non Medicare Eyewear	10		000000000000000000000100	1	200.00	2			2		2		2							
H5106	013	0	1	04	01	H5106_013_0	11	2	Preventive Services	01	0000000000000000000000000000011000000		2		2			2		2		2							
H5106	013	0	1	04	01	H5106_013_0	11	3	Coinsurance	11	0111110110111110000011110111000001011	000000100000000000000010	2		2			2		2		1		30		30			
H5106	013	0	1	04	01	H5106_013_0	11	4	Ambulance	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		1		30		30			
H5106	013	0	1	04	01	H5106_013_0	11	5	Transportation and Preventive Dental	10		000000010000000000100000	2		2			2		2		1		50		50			
H5106	013	0	1	04	01	H5106_013_0	11	6	Fitness Benefit	10		000000000000000010000000	2		2			1	500.00	2		1		50		50			
H5106	013	0	1	04	01	H5106_013_0	11	7	Primary Care Physician	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H5106	013	0	1	04	01	H5106_013_0	11	8	Specialist Physician	01	0000000001000000000000000000000000000		2		1	45.00	45.00	2		2		2							
H5106	013	0	1	04	01	H5106_013_0	11	9	End Stage Renal and Part B Drugs	01	0000000000000000000000000000100010000		2		2			2		2		1		0		30			
H5106	013	0	1	04	01	H5106_013_0	11	12	Diabetes Self Management Training	01	0000000000000000000000000000000100000		2		2			2		1	2	2					1	30.00	45.00
H5106	013	0	1	04	01	H5106_013_0	11	1	Copay and Coinsurance	11	0000000000000001111100000000000000100	000000000000000000001000	2		2			2		1	2	1		30		30	1	30.00	45.00
H5106	027	0	1	04	01	H5106_027_0	13	11	Hearing Aids	10		000000000000000000000001	1	500.00	2			2		2		2							
H5106	027	0	1	04	01	H5106_027_0	13	1	Copay and Coinsurance	11	0000000000000001111100000000000000100	000000000000000000001000	2		2			2		1	2	1		30		30	1	30.00	50.00
H5106	027	0	1	04	01	H5106_027_0	13	2	Preventive Services	01	0000000000000000000000000000011000000		2		2			2		2		2							
H5106	027	0	1	04	01	H5106_027_0	13	3	Coinsurance	11	0111110110111110000011110111000001011	000000100000000000000010	2		2			2		2		1		30		30			
H5106	027	0	1	04	01	H5106_027_0	13	4	Ambulance	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		1		30		30			
H5106	027	0	1	04	01	H5106_027_0	13	5	Transportation and Preventive Dental	10		000000010000000000100000	2		2			2		2		1		50		50			
H5106	027	0	1	04	01	H5106_027_0	13	6	Fitness Benefit	10		000000000000000010000000	2		2			1	500.00	2		1		50		50			
H5106	027	0	1	04	01	H5106_027_0	13	7	Primary Care Physician	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H5106	027	0	1	04	01	H5106_027_0	13	8	Specialist Physician	01	0000000001000000000000000000000000000		2		1	50.00	50.00	2		2		2							
H5106	027	0	1	04	01	H5106_027_0	13	9	End Stage Renal and Part B Drugs	01	0000000000000000000000000000100010000		2		2			2		2		1		0		30			
H5106	027	0	1	04	01	H5106_027_0	13	12	Diabetes Self Management Training	01	0000000000000000000000000000000100000		2		2			2		1	2	2					1	30.00	50.00
H5106	027	0	1	04	01	H5106_027_0	13	10	Non Medicare Eyewear	10		000000000000000000000100	1	200.00	2			2		2		2							
H5106	806	0	1	04	01	H5106_806_0	7	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5106	806	0	1	04	01	H5106_806_0	7	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5106	807	0	1	04	01	H5106_807_0	7	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5106	807	0	1	04	01	H5106_807_0	7	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5106	808	0	1	04	01	H5106_808_0	7	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5106	808	0	1	04	01	H5106_808_0	7	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5141	001	0	1	04	01	H5141_001_0	7	2	Non-Medicare Covered	10		000000000000000010000000	2		2			2		2		2							
H5141	001	0	1	04	01	H5141_001_0	7	3	Non-Medicare Covered Eyewear	10		000000000000000000000100	1	100.00	2			2		2		2							
H5141	001	0	1	04	01	H5141_001_0	7	4	OTC	10		000000000100000000000000	1	65.00	2			2		2		2							
H5141	001	0	1	04	01	H5141_001_0	7	1	Medicare Covered	11	0111111111111111111111111111111111111	000000000000000000001000	2		2			2		2		1		35		35			
H5141	003	0	1	04	01	H5141_003_0	6	3	Non-Medicare Covered	10		000001010000000010100000	2		2			2		2		2							
H5141	003	0	1	04	01	H5141_003_0	6	1	Medicare Covered	01	0111111111111111111111111111111111111		2		2			2		2		1		20		20			
H5141	003	0	1	04	01	H5141_003_0	6	2	OTC	10		000000000100000000000000	1	150.00	2			2		2		2							
H5141	004	0	1	04	01	H5141_004_0	6	3	OTC	10		000000000100000000000000	1	40.00	2			2		2		2							
H5141	004	0	1	04	01	H5141_004_0	6	1	Medicare Covered	01	0111111111111111111111111111111111111		2		2			2		2		1		35		35			
H5141	004	0	1	04	01	H5141_004_0	6	2	Non-Medicare Covered	10		000000000000000010000000	2		2			2		2		2							
H5215	001	0	1	04	01	H5215_001_0	6	3	50%	11	0111111111111111111111110111111111111	000000000000000100000000	2		2			2		2		1		50		50			
H5215	001	0	1	04	01	H5215_001_0	6	2	$36 Copay	10		010000000001000000000000	2		1	36.00	36.00	2		2		2							
H5215	001	0	1	04	01	H5215_001_0	6	1	$200	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H5215	001	0	1	04	01	H5215_001_0	6	4	50% + $3072 limit	10		000000000000000010000000	1	3072.00	2			2		2		1		50		50			
H5215	001	0	1	04	01	H5215_001_0	6	5	50% + $938.58 limit	10		000000000000100000000000	1	938.58	2			2		2		1		50		50			
H5215	002	0	1	04	01	H5215_002_0	6	1	$200	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H5215	002	0	1	04	01	H5215_002_0	6	2	$36 Copay	10		010000000001000000000000	2		1	36.00	36.00	2		2		2							
H5215	002	0	1	04	01	H5215_002_0	6	3	50%	11	0111111111111111111111110111111111111	000000000000000100000000	2		2			2		2		1		50		50			
H5215	002	0	1	04	01	H5215_002_0	6	4	50% + $3072 limit	10		000000000000000010000000	1	3072.00	2			2		2		1		50		50			
H5215	002	0	1	04	01	H5215_002_0	6	5	50% + $938.58 limit	10		000000000000100000000000	1	938.58	2			2		2		1		50		50			
H5215	005	0	1	04	01	H5215_005_0	7	1	$0	01	0000000000000000000000001000000000000		2		2			2		2		2							
H5215	005	0	1	04	01	H5215_005_0	7	6	50% + $3072 limit	10		000000000000000010000000	1	3072.00	2			2		2		1		50		50			
H5215	005	0	1	04	01	H5215_005_0	7	5	50% + $938.58 limit	10		000000000000100000000000	1	938.58	2			2		2		1		50		50			
H5215	005	0	1	04	01	H5215_005_0	7	4	$0 + limit	10		000000000000000000000001	1	75.00	2			2		2		2							
H5215	005	0	1	04	01	H5215_005_0	7	3	50%	11	0111111111111111111111110111111111111	000000000000000100000010	2		2			2		2		1		50		50			
H5215	005	0	1	04	01	H5215_005_0	7	2	$36 Copay	10		010000000001000000000000	2		1	36.00	36.00	2		2		2							
H5215	006	0	1	04	01	H5215_006_0	6	5	50% + $938.58 limit	10		000000000000100000000000	1	938.58	2			2		2		1		50		50			
H5215	006	0	1	04	01	H5215_006_0	6	4	$0 + limit	10		000000000000000000000001	1	75.00	2			2		2		2							
H5215	006	0	1	04	01	H5215_006_0	6	3	50%	11	0111111111111111111111110111111111111	000000000000000100000010	2		2			2		2		1		50		50			
H5215	006	0	1	04	01	H5215_006_0	6	2	$36 Copay	10		010000000001000000000000	2		1	36.00	36.00	2		2		2							
H5215	006	0	1	04	01	H5215_006_0	6	1	$0	01	0000000000000000000000001000000000000		2		2			2		2		2							
H5215	006	0	1	04	01	H5215_006_0	6	6	50% + $3072 limit	10		000000000000000010000000	1	3072.00	2			2		2		1		50		50			
H5215	007	0	1	04	01	H5215_007_0	7	3	20%	01	0111101111111111111111111111111111111		2		2			2		2		1		20		20			
H5215	007	0	1	04	01	H5215_007_0	7	2	$36	10		010000000000000000000000	2		1	36.00	36.00	2		2		2							
H5215	007	0	1	04	01	H5215_007_0	7	1	$0	11	0000010000000000000000000000000000000	000000000000000000001000	2		2			2		2		2							
H5215	007	0	1	04	01	H5215_007_0	7	4	50% + $938.58 limit	10		000000000000100000000000	1	938.58	2			2		2		1		50		50			
H5215	007	0	1	04	01	H5215_007_0	7	8	20-50%	10		000000000000000000010000	2		2			2		2		1		20		50			
H5215	007	0	1	04	01	H5215_007_0	7	7	0-50% + $3122 limit	10		000000000000000010000000	1	3122.00	2			2		2		1		0		50			
H5215	007	0	1	04	01	H5215_007_0	7	6	0% + $3500 limit	10		000000000000000000100000	1	3500.00	2			2		2		2							
H5215	007	0	1	04	01	H5215_007_0	7	5	$0 + $400 limit	10		000000000000000000000100	1	400.00	2			2		2		2							
H5215	008	0	1	04	01	H5215_008_0	6	1	$0	01	0000000000000000000000000000000100000		2		2			2		2		2							
H5215	008	0	1	04	01	H5215_008_0	6	10	$200	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H5215	008	0	1	04	01	H5215_008_0	6	9	$175	01	0000000000000000010000000000000000000		2		1	175.00	175.00	2		2		2							
H5215	008	0	1	04	01	H5215_008_0	6	8	$55	01	0000000001011000000000000000000000000		2		1	55.00	55.00	2		2		2							
H5215	008	0	1	04	01	H5215_008_0	6	7	$50	01	0000000000000000000100000000000000100		2		1	50.00	50.00	2		2		2							
H5215	008	0	1	04	01	H5215_008_0	6	6	$45	01	0000000110100110000000100000000001011		2		1	45.00	45.00	2		2		2							
H5215	008	0	1	04	01	H5215_008_0	6	5	$30	11	0000001000000000000000000000000000000	000000000000000100000000	2		1	30.00	30.00	2		2		2							
H5215	008	0	1	04	01	H5215_008_0	6	11	$300-$400	01	0000000000000000000011000000000000000		2		1	300.00	400.00	2		2		2							
H5215	008	0	1	04	01	H5215_008_0	6	12	$60	01	0000100000000000000000000000000000000		2		1	60.00	60.00	2		2		2							
H5215	008	0	1	04	01	H5215_008_0	6	13	20%-50%	01	0000010000000000001000000110100010000		2		2			2		2		1		20		50			
H5215	008	0	1	04	01	H5215_008_0	6	14	50% + $3072 limit	10		000000000000000010000000	1	3072.00	2			2		2		1		50		50			
H5215	008	0	1	04	01	H5215_008_0	6	15	50%+$938.58 limit	10		000000000000100000000000	1	938.58	2			2		2		1		50		50			
H5215	008	0	1	04	01	H5215_008_0	6	2	$20-$45	01	0000000000000001000000000000000000000		2		1	20.00	45.00	2		2		2							
H5215	008	0	1	04	01	H5215_008_0	6	3	$20	01	0000000000000000100000000000011000000		2		1	20.00	20.00	2		2		2							
H5215	008	0	1	04	01	H5215_008_0	6	4	$36-$40	11	0111000000000000000000010001000000000	010000000001000000000000	2		1	36.00	40.00	2		2		2							
H5215	806	0	1	04	01	H5215_806_0	4	1	0%	01	0000010000000000000000000000000000000		2		2			2		2		2							
H5215	806	0	1	04	01	H5215_806_0	4	2	20%	01	0111101111111111111111111111111111111		2		2			2		2		1		20		20			
H5215	807	0	1	04	01	H5215_807_0	4	1	0%	01	0000010000000000000000000000000000000		2		2			2		2		2							
H5215	807	0	1	04	01	H5215_807_0	4	2	20%	01	0111101111111111111111111111111111111		2		2			2		2		1		20		20			
H5215	808	0	1	04	01	H5215_808_0	4	1	0%	01	0000010000000000000000000000000000000		2		2			2		2		2							
H5215	808	0	1	04	01	H5215_808_0	4	2	20%	01	0111101111111111111111111111111111111		2		2			2		2		1		20		20			
H5216	001	0	1	04	01	H5216_001_0	3	5		01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5216	001	0	1	04	01	H5216_001_0	3	4		01	0000000000000000000000000000010000000		2		2			2		2		1		0		50			
H5216	001	0	1	04	01	H5216_001_0	3	3		01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H5216	001	0	1	04	01	H5216_001_0	3	2		10		000000000000000000001000	1	40.00	1	0.00	0.00	2		2		2							
H5216	001	0	1	04	01	H5216_001_0	3	1		11	0000000000000000000000010000000000010	000000100000000000000000	2		1	0.00	0.00	2		2		2							
H5216	001	0	1	04	01	H5216_001_0	3	6		01	0000000000000000000010000000000000000		2		2			2		2		1		20		50			
H5216	001	0	1	04	01	H5216_001_0	3	7		11	0111111111111111111101100111001111101	000000000010000110110000	2		2			2		2		1		50		50			
H5216	001	0	1	04	01	H5216_001_0	3	8		10		000000000100000000000000	1	50.00	2			2		2		1		50		50			
H5216	003	0	1	04	01	H5216_003_0	3	4		01	0000000000000000000000000000010000000		2		2			2		2		1		0		50			
H5216	003	0	1	04	01	H5216_003_0	3	3		01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H5216	003	0	1	04	01	H5216_003_0	3	2		10		000000000000000000001000	1	40.00	1	0.00	0.00	2		2		2							
H5216	003	0	1	04	01	H5216_003_0	3	10		10		000000000100000000000000	1	50.00	2			2		2		1		50		50			
H5216	003	0	1	04	01	H5216_003_0	3	1		11	0000000000000000000000010000000000010	000000100000000000000000	2		1	0.00	0.00	2		2		2							
H5216	003	0	1	04	01	H5216_003_0	3	5		01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5216	003	0	1	04	01	H5216_003_0	3	9		11	0111111111111111111101100010001111101	000000000010000110110000	2		2			2		2		1		50		50			
H5216	003	0	1	04	01	H5216_003_0	3	8		01	0000000000000000000000000001000000000		2		2			2		2		1		40		40			
H5216	003	0	1	04	01	H5216_003_0	3	7		01	0000000000000000000000000100000000000		2		2			2		2		1		30		30			
H5216	003	0	1	04	01	H5216_003_0	3	6		01	0000000000000000000010000000000000000		2		2			2		2		1		20		50			
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H5216	006	0	1	04	01	H5216_006_0	3	3		01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H5216	006	0	1	04	01	H5216_006_0	3	4		01	0000000000000000000000000000010000000		2		2			2		2		1		0		50			
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H5415	056	0	1	04	01	H5415_056_0	4	7		01	0000000000000000000010000000000010000		2		2			2		2		1		20		30			
H5415	056	0	1	04	01	H5415_056_0	4	6		01	0000000000000000000000000000100000000		2		2			2		2		1		0		20			
H5415	056	0	1	04	01	H5415_056_0	4	5		11	0000001101111100000000000000001001101	000000000000000100000000	2		1	40.00	40.00	2		2		2							
H5415	056	0	1	04	01	H5415_056_0	4	4		01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H5415	056	0	1	04	01	H5415_056_0	4	3		10		000000000000000000001000	1	40.00	1	0.00	0.00	2		2		2							
H5415	056	0	1	04	01	H5415_056_0	4	2		10		000000000000000000000100	1	100.00	1	0.00	0.00	2		2		2							
H5415	056	0	1	04	01	H5415_056_0	4	9		01	0000110000000000010001100101000000000		2		2			2		2		1		30		30			
H5415	056	0	1	04	01	H5415_056_0	4	12		10		000000000010000010110000	2		2			2		2		1		50		50			
H5415	056	0	1	04	01	H5415_056_0	4	11		01	0000000000000000000000000000010000000		2		1	0.00	40.00	2		2		1		30		50			
H5415	056	0	1	04	01	H5415_056_0	4	10		01	0111000010000011101100000000000100000		2		1	40.00	40.00	2		2		1		30		30			
H5415	056	0	1	04	01	H5415_056_0	4	1		11	0000000000000000000000010000000000010	000000100000000000000000	2		1	0.00	0.00	2		2		2							
H5415	056	0	1	04	01	H5415_056_0	4	8		01	0000000000000000000000000010000000000		2		2			2		2		1		25		25			
H5415	056	0	1	04	01	H5415_056_0	4	13		10		000000000100000000000000	1	10.00	2			2		2		1		50		50			
H5415	070	0	1	04	01	H5415_070_0	3	7		01	0000000000000000000010000000000010000		2		2			2		2		1		20		40			
H5415	070	0	1	04	01	H5415_070_0	3	6		01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5415	070	0	1	04	01	H5415_070_0	3	5		11	0000001101111100000000000000001001101	000000000000000100000000	2		1	40.00	40.00	2		2		2							
H5415	070	0	1	04	01	H5415_070_0	3	4		01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H5415	070	0	1	04	01	H5415_070_0	3	3		10		000000000000000000001000	1	40.00	1	0.00	0.00	2		2		2							
H5415	070	0	1	04	01	H5415_070_0	3	2		10		000000000000000000000100	1	100.00	1	0.00	0.00	2		2		2							
H5415	070	0	1	04	01	H5415_070_0	3	13		10		000000000100000000000000	1	10.00	2			2		2		1		50		50			
H5415	070	0	1	04	01	H5415_070_0	3	12		10		000000000010000010000000	2		2			2		2		1		50		50			
H5415	070	0	1	04	01	H5415_070_0	3	11		01	0000000000000000000000000000010000000		2		1	0.00	40.00	2		2		1		40		50			
H5415	070	0	1	04	01	H5415_070_0	3	10		01	0111000010000011101100000000000100000		2		1	40.00	40.00	2		2		1		40		40			
H5415	070	0	1	04	01	H5415_070_0	3	1		11	0000000000000000000000010000000000010	000000100000000000000000	2		1	0.00	0.00	2		2		2							
H5415	070	0	1	04	01	H5415_070_0	3	8		01	0000000000000000000000000100000000000		2		2			2		2		1		25		25			
H5415	070	0	1	04	01	H5415_070_0	3	9		01	0000110000000000010001100011000000000		2		2			2		2		1		40		40			
H5415	801	0	1	04	01	H5415_801_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5415	801	0	1	04	01	H5415_801_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5415	803	0	1	04	01	H5415_803_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5415	803	0	1	04	01	H5415_803_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5415	804	0	1	04	01	H5415_804_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5415	804	0	1	04	01	H5415_804_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5415	806	0	2	04	01	H5415_806_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5415	806	0	2	04	01	H5415_806_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5415	807	0	2	04	01	H5415_807_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5415	807	0	2	04	01	H5415_807_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5415	808	0	2	04	01	H5415_808_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5415	808	0	2	04	01	H5415_808_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5415	815	0	1	04	01	H5415_815_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5415	815	0	1	04	01	H5415_815_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5417	001	0	1	04	01	H5417_001_0	5	3	Group 3	01	0000000000000000000000001000100000000		2		2			2		2		1		20		20			
H5417	001	0	1	04	01	H5417_001_0	5	9	Group 9	10		000000000000000000000001	1	1000.00	1	0.00	0.00	2		2		2							
H5417	001	0	1	04	01	H5417_001_0	5	5	Group 5	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H5417	001	0	1	04	01	H5417_001_0	5	6	Group 6	01	0000000000000001111100000000000000000		2		2			2		1	1	1	30	0	30	30	2		
H5417	001	0	1	04	01	H5417_001_0	5	7	Group 7	10		000000000000000000100000	1	250.00	1	0.00	0.00	2		2		2							
H5417	001	0	1	04	01	H5417_001_0	5	8	Group 8	10		000000000000000000000100	1	150.00	1	0.00	0.00	2		2		2							
H5417	001	0	1	04	01	H5417_001_0	5	2	Group 2	11	0000000000000000000000000000000000010	000000000000000000010000	2		1	0.00	0.00	2		2		2							
H5417	001	0	1	04	01	H5417_001_0	5	1	Group 1	11	0111111111111110000011110111001111101	000001100000000000001010	2		2			2		2		1		30		30			
H5417	001	0	1	04	01	H5417_001_0	5	4	Group 4	10		000000010000000000000000	2		2			2		2		1		75		75			
H5424	001	0	1	04	01	H5424_001_0	2	1	Group 1	01	0000001000000000000000000000000000000		2		1	35.00	35.00	2		2		2							
H5424	001	0	1	04	01	H5424_001_0	2	10	Group 10	11	0000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H5424	001	0	1	04	01	H5424_001_0	2	11	Group 11	01	0000000000000000000000000000010000000		2		2			2		2		1		0		40			
H5424	001	0	1	04	01	H5424_001_0	2	12	Group 12	01	0000010000000000000000000100000000000		2		2			2		2		1		50		50			
H5424	001	0	1	04	01	H5424_001_0	2	13	Group 13	01	0000000000001000000000000000000000000		2		1	35.00	65.00	2		2		2							
H5424	001	0	1	04	01	H5424_001_0	2	14	Group 14	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H5424	001	0	1	04	01	H5424_001_0	2	2	Group 2	11	0111000111010010000000000000000001101	000011001000000000001010	2		1	65.00	65.00	2		2		2							
H5424	001	0	1	04	01	H5424_001_0	2	3	Group 3	11	0000000000000000000011000011001110010	000000000000000100000000	2		2			2		2		1		40		40			
H5424	001	0	1	04	01	H5424_001_0	2	4	Group 4	01	0000000000000001111100000000000000000		2		1	13.00	21.00	2		1	2	1		40		40	1	35.00	65.00
H5424	001	0	1	04	01	H5424_001_0	2	5	Group 5	10		000000000000000000000100	1	70.00	1	0.00	0.00	2		2		2							
H5424	001	0	1	04	01	H5424_001_0	2	6	Group 6	01	0000100000000000000000000000000000000		2		1	75.00	75.00	2		2		2							
H5424	001	0	1	04	01	H5424_001_0	2	7	Group 7	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H5424	001	0	1	04	01	H5424_001_0	2	8	Group 8	01	0000000000100100000000100000000000000		2		1	35.00	45.00	2		2		2							
H5424	001	0	1	04	01	H5424_001_0	2	9	Group 9	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5424	003	0	1	04	01	H5424_003_0	1	1	Group 1	01	0000001000000000000000000000000000000		2		1	35.00	35.00	2		2		2							
H5424	003	0	1	04	01	H5424_003_0	1	10	Group 10	11	0000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H5424	003	0	1	04	01	H5424_003_0	1	9	Group 9	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5424	003	0	1	04	01	H5424_003_0	1	8	Group 8	01	0000000000100100000000100000000000000		2		1	35.00	45.00	2		2		2							
H5424	003	0	1	04	01	H5424_003_0	1	7	Group 7	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H5424	003	0	1	04	01	H5424_003_0	1	6	Group 6	01	0000100000000000000000000000000000000		2		1	75.00	75.00	2		2		2							
H5424	003	0	1	04	01	H5424_003_0	1	5	Group 5	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H5424	003	0	1	04	01	H5424_003_0	1	4	Group 4	01	0000000000000001111100000000000000000		2		1	13.00	21.00	2		1	2	1		40		40	1	35.00	65.00
H5424	003	0	1	04	01	H5424_003_0	1	11	Group 11	01	0000000000000000000000000000010000000		2		2			2		2		1		0		40			
H5424	003	0	1	04	01	H5424_003_0	1	12	Group 12	01	0000010000000000000000000100000000000		2		2			2		2		1		50		50			
H5424	003	0	1	04	01	H5424_003_0	1	13	Group 13	01	0000000000001000000000000000000000000		2		1	35.00	65.00	2		2		2							
H5424	003	0	1	04	01	H5424_003_0	1	14	Group 14	10		000000000000000000000100	1	70.00	1	0.00	0.00	2		2		2							
H5424	003	0	1	04	01	H5424_003_0	1	2	Group 2	11	0111000111010010000000000000000001101	000011001000000000001010	2		1	65.00	65.00	2		2		2							
H5424	003	0	1	04	01	H5424_003_0	1	3	Group 3	11	0000000000000000000011000011001110010	000000000000000100000000	2		2			2		2		1		40		40			
H5424	005	0	1	04	01	H5424_005_0	3	6	Group 6	10		000000000100000000000000	1	100.00	1	0.00	0.00	2		2		2							
H5424	005	0	1	04	01	H5424_005_0	3	5	Group 5	01	0000000000000001111100000000000000000		2		2			2		1	1	1	30	0	30	30	2		
H5424	005	0	1	04	01	H5424_005_0	3	4	Group 4	11	0000000000000000000000000000000000010	000000000000000000010000	2		1	0.00	0.00	2		2		2							
H5424	005	0	1	04	01	H5424_005_0	3	3	Group 3	01	0000000000000000000000001000100010000		2		2			2		2		1		20		20			
H5424	005	0	1	04	01	H5424_005_0	3	2	Group 2	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H5424	005	0	1	04	01	H5424_005_0	3	1	Group 1	11	0111111111111110000011110111001101101	000001100000000000000000	2		2			2		2		1		30		30			
H5424	005	0	1	04	01	H5424_005_0	3	7	Group 7	10		000000000000000000100000	1	1000.00	1	0.00	0.00	2		2		2							
H5434	002	0	1	04	01	H5434_002_0	9	6	Dental - 50%	10		000000000000000000110000	1	1000.00	2			2		2		1		50		50			
H5434	002	0	1	04	01	H5434_002_0	9	2	50% DME & Part B Drugs	01	0000010000000000000000000100000010000		2		2			2		2		1		50		50			
H5434	002	0	1	04	01	H5434_002_0	9	3	Ambulance	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H5434	002	0	1	04	01	H5434_002_0	9	4	20%	01	0000000000000000000000000001100000000		2		2			2		2		1		20		20			
H5434	002	0	1	04	01	H5434_002_0	9	7	Eyewear	10		000000000000000000000100	1	100.00	1	20.00	225.00	2		2		2							
H5434	002	0	1	04	01	H5434_002_0	9	5	$0 Copayment	10		000000000000000010001010	2		2			2		2		2							
H5434	002	0	1	04	01	H5434_002_0	9	1	30%	11	0111101111111111111111110010011101111	000001100000000000000000	2		2			2		2		1		30		30			
H5434	002	0	1	04	01	H5434_002_0	9	8	Hearing Aids	10		000000000000000000000001	1	1000.00	2			2		2		2							
H5434	801	0	1	04	01	H5434_801_0	7	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5434	801	0	1	04	01	H5434_801_0	7	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5434	802	0	1	04	01	H5434_802_0	5	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5434	802	0	1	04	01	H5434_802_0	5	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5439	001	0	1	04	01	H5439_001_0	2	9	Group 9 - 5%	01	0000010000000000000000000000000000000		2		2			2		2		1		5		5			
H5439	001	0	1	04	01	H5439_001_0	2	8	Group 8 - 30%	01	0000000000000000000001000000000000000		2		2			2		2		1		30		30			
H5439	001	0	1	04	01	H5439_001_0	2	5	Group 5 - $50	01	0000100100100100000000100000000000000		2		1	50.00	50.00	2		2		2							
H5439	001	0	1	04	01	H5439_001_0	2	6	Group 6 - $30	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H5439	001	0	1	04	01	H5439_001_0	2	7	Group 7 - $40	01	0000000001000000000000000000000000000		2		1	40.00	40.00	2		2		2							
H5439	001	0	1	04	01	H5439_001_0	2	4	Group 4 - $0	11	0000000000000000000000000000011100010	000000000000000010000000	2		1	0.00	0.00	2		2		2							
H5439	001	0	1	04	01	H5439_001_0	2	3	Group 3 - $35	01	0111000010010010000000000000000000000		2		1	35.00	35.00	2		2		2							
H5439	001	0	1	04	01	H5439_001_0	2	2	Group 2 - $275	01	0000000000000000000000001000000000000		2		1	275.00	275.00	2		2		2							
H5439	001	0	1	04	01	H5439_001_0	2	15	Group 15 - $30 or $40	01	0000000000001000000000000000000000000		2		1	30.00	40.00	2		2		2							
H5439	001	0	1	04	01	H5439_001_0	2	14	Group 14 - 20%	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5439	001	0	1	04	01	H5439_001_0	2	13	Group 13 - 10% to 30%	01	0000000000000000000010000000000000000		2		2			2		2		1		10		30			
H5439	001	0	1	04	01	H5439_001_0	2	12	Group 12 - 10% or 15%	01	0000000000000000000000000010000000000		2		2			2		2		1		10		15			
H5439	001	0	1	04	01	H5439_001_0	2	11	Group 11 - 0% or 10%	11	0000000000000000000000000000000000100	000000000000000000001000	2		2			2		2		1		0		10			
H5439	001	0	1	04	01	H5439_001_0	2	10	Group 10 - 15% or 20%	01	0000000000000000000000000001000000000		2		2			2		2		1		15		20			
H5439	001	0	1	04	01	H5439_001_0	2	1	Group 1 - 10%	11	0000000000000001111100010100000011001	000000100000000100000010	2		2			2		2		1		10		10			
H5439	005	0	1	04	01	H5439_005_0	2	3	Group 3 - $40	01	0111100111110110000000000000000000000		2		1	40.00	40.00	2		2		2							
H5439	005	0	1	04	01	H5439_005_0	2	4	Group 4 - $0	11	0000010000000000000000000000011101010	000000000000000010000000	2		1	0.00	0.00	2		2		2							
H5439	005	0	1	04	01	H5439_005_0	2	2	Group 2 - $345	01	0000000000000000000000001000000000000		2		1	345.00	345.00	2		2		2							
H5439	005	0	1	04	01	H5439_005_0	2	1	Group 1 - $35	01	0000001000000000000000000000000000000		2		1	35.00	35.00	2		2		2							
H5439	005	0	1	04	01	H5439_005_0	2	5	Group 5 - 0% or 30%	11	0000000000000000000000000000000000100	000000000000000000001000	2		2			2		2		1		0		30			
H5439	005	0	1	04	01	H5439_005_0	2	9	Group 9 - 20%	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5439	005	0	1	04	01	H5439_005_0	2	8	Group 8 - 10%	11	0000000000000000000000000110000010000	000000000000000100000000	2		2			2		2		1		10		10			
H5439	005	0	1	04	01	H5439_005_0	2	7	Group 7 - 10% or 20%	01	0000000000000000000000000001000000000		2		2			2		2		1		10		20			
H5439	005	0	1	04	01	H5439_005_0	2	6	Group 6 - 30%	11	0000000000000001111111110000000000001	000000100000000000000000	2		2			2		2		1		30		30			
H5439	005	0	1	04	01	H5439_005_0	2	10	Group 10 - $35 or 40	01	0000000000001000000000000000000000000		2		1	35.00	40.00	2		2		2							
H5439	007	0	1	04	01	H5439_007_0	2	1	Group 1 - $30	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H5439	007	0	1	04	01	H5439_007_0	2	10	Group 10 - $30 or $40	01	0000000000001000000000000000000000000		2		1	30.00	40.00	2		2		2							
H5439	007	0	1	04	01	H5439_007_0	2	3	Group 3 - $40	01	0111100111110110000000000000000000000		2		1	40.00	40.00	2		2		2							
H5439	007	0	1	04	01	H5439_007_0	2	2	Group 2 - $315	01	0000000000000000000000001000000000000		2		1	315.00	315.00	2		2		2							
H5439	007	0	1	04	01	H5439_007_0	2	4	Group 4 - $0	11	0000010000000000000000000000011101010	000000000000000010000000	2		1	0.00	0.00	2		2		2							
H5439	007	0	1	04	01	H5439_007_0	2	5	Group 5 - 0% or 30%	11	0000000000000000000000000000000000100	000000000000000000001000	2		2			2		2		1		0		30			
H5439	007	0	1	04	01	H5439_007_0	2	6	Group 6 - 30%	11	0000000000000001111111110000000000001	000000100000000000000000	2		2			2		2		1		30		30			
H5439	007	0	1	04	01	H5439_007_0	2	7	Group 7 - 10% or 20%	01	0000000000000000000000000001000000000		2		2			2		2		1		10		20			
H5439	007	0	1	04	01	H5439_007_0	2	9	Group 9 - 20%	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5439	007	0	1	04	01	H5439_007_0	2	8	Group 8 - 10%	11	0000000000000000000000000110000010000	000000000000000100000000	2		2			2		2		1		10		10			
H5439	801	0	1	04	01	H5439_801_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5439	801	0	1	04	01	H5439_801_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5439	802	0	1	04	01	H5439_802_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5439	802	0	1	04	01	H5439_802_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5439	803	0	1	04	01	H5439_803_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5439	803	0	1	04	01	H5439_803_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5507	001	0	1	04	01	H5507_001_0	2	1	Group 1	11	0111001111011010000011000011001111111	000001000000000100001010	2		2			2		2		1		30		30			
H5507	001	0	1	04	01	H5507_001_0	2	10	Group 10	01	0000010000000000000000000100000000000		2		2			2		2		1		50		50			
H5507	001	0	1	04	01	H5507_001_0	2	9	Group 9	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H5507	001	0	1	04	01	H5507_001_0	2	8	Group 8	11	0000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H5507	001	0	1	04	01	H5507_001_0	2	7	Group 7	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5507	001	0	1	04	01	H5507_001_0	2	6	Group 6	01	0000000000100100000000100000000000000		2		1	35.00	45.00	2		2		2							
H5507	001	0	1	04	01	H5507_001_0	2	5	Group 5	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H5507	001	0	1	04	01	H5507_001_0	2	4	Group 4	01	0000100000000000000000000000000000000		2		1	75.00	75.00	2		2		2							
H5507	001	0	1	04	01	H5507_001_0	2	3	Group 3	10		000000000000000000100000	2		2			2		2		1		75		75			
H5507	001	0	1	04	01	H5507_001_0	2	11	Group 11	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H5507	001	0	1	04	01	H5507_001_0	2	12	Group 12	10		000000000000000000000100	1	105.00	2			2		2		1		30		30			
H5507	001	0	1	04	01	H5507_001_0	2	2	Group 2	01	0000000000000001111100000000000000000		2		1	13.00	21.00	2		1	1	1	30	30	30	30	2		
H5508	001	0	1	04	01	H5508_001_0	14	4		10		000000000000000000100000	2		2			2		2		1		50		50			
H5508	001	0	1	04	01	H5508_001_0	14	3		01	0000000000100000000000000000000000000		2		2			2		2		1		35		35			
H5508	001	0	1	04	01	H5508_001_0	14	2		01	0000000000000000000000000000011100000		2		1	20.00	20.00	2		2		2							
H5508	001	0	1	04	01	H5508_001_0	14	1		11	0111111111011111111111111111100011111	000000100000000010001100	2		2			2		2		1		20		20			
H5508	002	0	1	04	01	H5508_002_0	11	3		01	0000000000100000000000000000000000000		2		2			2		2		1		35		35			
H5508	002	0	1	04	01	H5508_002_0	11	2		01	0000000000000000000000000000011100000		2		2			2		2		1		0		0			
H5508	002	0	1	04	01	H5508_002_0	11	1		11	0111111111011111111111111111100011111	000000100000000010001100	2		2			2		2		1		20		20			
H5508	002	0	1	04	01	H5508_002_0	11	4		10		000000000000000000100000	2		2			2		2		1		50		50			
H5508	005	0	1	04	01	H5508_005_0	15	1		01	0111111111111111111111111111100011111		2		2			2		2		1		20		20			
H5508	005	0	1	04	01	H5508_005_0	15	4		11	0000000000000000000000000000011100000	000000100000000000000000	2		2			2		2		1		20		20			
H5508	005	0	1	04	01	H5508_005_0	15	3		01	0000000000000001000000000000000000000		2		2			2		2		1		35		35			
H5508	005	0	1	04	01	H5508_005_0	15	2		10		000000000000000010000000	1	150.00	2			2		2		1		20		20			
H5508	006	0	1	04	01	H5508_006_0	13	1		11	0111111111011111111111111111100011111	000000100000000000001000	2		2			2		2		1		20		20			
H5508	006	0	1	04	01	H5508_006_0	13	2		11	0000000000000000000000000000011100000	000000000000000010000000	2		1	0.00	0.00	2		2		2							
H5508	006	0	1	04	01	H5508_006_0	13	3		01	0000000000100000000000000000000000000		2		2			2		2		1		35		35			
H5508	006	0	1	04	01	H5508_006_0	13	4		10		000000000000000000101100	2		2			2		2		1		50		50			
H5508	801	0	1	04	01	H5508_801_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5508	801	0	1	04	01	H5508_801_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5508	802	0	1	04	01	H5508_802_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5508	802	0	1	04	01	H5508_802_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5508	803	0	1	04	01	H5508_803_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5508	803	0	1	04	01	H5508_803_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5508	804	0	1	04	01	H5508_804_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5508	804	0	1	04	01	H5508_804_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5509	001	0	1	04	01	H5509_001_0	7	1	Group 1	11	0111101111111110000011110000111011111	000000100000000000001000	2		2			2		2		1		45		45			
H5509	001	0	1	04	01	H5509_001_0	7	2	Group 2	11	0000010000000000000000000000000000000	000000010010000000000000	2		1	0.00	0.00	2		2		2							
H5509	001	0	1	04	01	H5509_001_0	7	5	Group 5	01	0000000000000000000000000111000000000		2		2			2		2		1		20		20			
H5509	001	0	1	04	01	H5509_001_0	7	4	Group 4	01	0000000000000000000000001000000000000		2		1	300.00	300.00	2		2		2							
H5509	001	0	1	04	01	H5509_001_0	7	3	Group 3	10		000000000000000010000000	2		1	0.00	50.00	2		2		1		45		45			
H5509	001	0	1	04	01	H5509_001_0	7	6		01	0000000000000001111100000000000100000		2		2			2		1	1	1	45	45	45	45	2		
H5509	003	0	1	04	01	H5509_003_0	4	4	Group 4	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H5509	003	0	1	04	01	H5509_003_0	4	5	Group 5	01	0000000000000000000000000111000000000		2		2			2		2		1		20		20			
H5509	003	0	1	04	01	H5509_003_0	4	6		01	0000000000000001111100000000000100000		2		2			2		1	1	1	45	45	45	45	2		
H5509	003	0	1	04	01	H5509_003_0	4	1	Group 1	11	0111101111111110000011110000111011111	000000100000000000001000	2		2			2		2		1		45		45			
H5509	003	0	1	04	01	H5509_003_0	4	2	Group 2	11	0000010000000000000000000000000000000	000000010010000000000000	2		1	0.00	0.00	2		2		2							
H5509	003	0	1	04	01	H5509_003_0	4	3	Group 3	10		000000000000000010000000	2		1	0.00	50.00	2		2		1		45		45			
H5509	010	0	1	04	01	H5509_010_0	6	2	Group 2	01	0000010000000000000000000000000000000		2		1	0.00	0.00	2		2		2							
H5509	010	0	1	04	01	H5509_010_0	6	1	Group 1	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H5509	010	0	1	04	01	H5509_010_0	6	3	Group 3	11	0111101111111110000011110000111011111	000000100000000000001000	2		2			2		2		1		45		45			
H5509	010	0	1	04	01	H5509_010_0	6	4	Group 4	10		000000000000000010000000	2		1	0.00	50.00	2		2		1		45		45			
H5509	010	0	1	04	01	H5509_010_0	6	5	Group 5	01	0000000000000000000000000111000000000		2		2			2		2		1		20		20			
H5509	010	0	1	04	01	H5509_010_0	6	6	Group 6	10		000000000000000000100000	1	250.00	2			2		2		2							
H5509	010	0	1	04	01	H5509_010_0	6	7		01	0000000000000001111100000000000100000		2		2			2		1	1	1	45	45	45	45	2		
H5509	011	0	1	04	01	H5509_011_0	5	2	Group 2	01	0000010000000000000000000000000000000		2		1	0.00	0.00	2		2		2							
H5509	011	0	1	04	01	H5509_011_0	5	1	Group 1	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H5509	011	0	1	04	01	H5509_011_0	5	3	Group 3	11	0111101111111110000011110000111011111	000000100000000000001000	2		2			2		2		1		45		45			
H5509	011	0	1	04	01	H5509_011_0	5	7		01	0000000000000001111100000000000100000		2		2			2		1	1	1	45	45	45	45	2		
H5509	011	0	1	04	01	H5509_011_0	5	6	Group 6	10		000000000000000000100000	1	300.00	2			2		2		2							
H5509	011	0	1	04	01	H5509_011_0	5	5	Group 5	01	0000000000000000000000000111000000000		2		2			2		2		1		20		20			
H5509	011	0	1	04	01	H5509_011_0	5	4	Group 4	10		000000000000000010000000	2		1	0.00	50.00	2		2		1		45		45			
H5509	012	0	1	04	01	H5509_012_0	4	1	Group 1	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H5509	012	0	1	04	01	H5509_012_0	4	5	Group 6	01	0000000000000000000000000111000000000		2		2			2		2		1		20		20			
H5509	012	0	1	04	01	H5509_012_0	4	4	Group 4	10		000000000000000010000000	2		1	0.00	50.00	2		2		1		45		45			
H5509	012	0	1	04	01	H5509_012_0	4	3	Group 3	11	0111101111111110000011110000111011111	000000100000000000001000	2		2			2		2		1		45		45			
H5509	012	0	1	04	01	H5509_012_0	4	2	Group 2	01	0000010000000000000000000000000000000		2		1	0.00	0.00	2		2		2							
H5509	012	0	1	04	01	H5509_012_0	4	6		01	0000000000000001111100000000000100000		2		2			2		1	1	1	45	45	45	45	2		
H5509	016	0	1	04	01	H5509_016_0	4	1	Group 1	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H5509	016	0	1	04	01	H5509_016_0	4	2	Group 2	01	0000010000000000000000000000000000000		2		1	0.00	0.00	2		2		2							
H5509	016	0	1	04	01	H5509_016_0	4	3	Group 3	11	0111101111111110000011110000111011111	000000100000000000001000	2		2			2		2		1		50		50			
H5509	016	0	1	04	01	H5509_016_0	4	4	Group 4	10		000000000000000010000000	2		1	0.00	50.00	2		2		1		50		50			
H5509	016	0	1	04	01	H5509_016_0	4	5	Group 5	01	0000000000000000000000000111000000000		2		2			2		2		1		20		20			
H5509	016	0	1	04	01	H5509_016_0	4	6	Group 6	10		000000000000000000100000	1	250.00	1	0.00	0.00	2		2		2							
H5509	016	0	1	04	01	H5509_016_0	4	7	Group 7	01	0000000000000001111100000000000100000		2		2			2		1	1	1	50	50	50	50	2		
H5509	017	0	1	04	01	H5509_017_0	5	5	Group 5	01	0000000000000000000000000111000000000		2		2			2		2		1		20		20			
H5509	017	0	1	04	01	H5509_017_0	5	4	Group 4	10		000000000000000010000000	2		1	0.00	50.00	2		2		1		45		45			
H5509	017	0	1	04	01	H5509_017_0	5	3	Group 3	11	0111101111111110000011110000111011111	000000100000000000001000	2		2			2		2		1		45		45			
H5509	017	0	1	04	01	H5509_017_0	5	2	Group 2	01	0000010000000000000000000000000000000		2		1	0.00	0.00	2		2		2							
H5509	017	0	1	04	01	H5509_017_0	5	1	Group 1	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H5509	017	0	1	04	01	H5509_017_0	5	6	Group 6	10		000000000000000000000100	1	125.00	1	0.00	0.00	2		2		2							
H5509	017	0	1	04	01	H5509_017_0	5	7	Group 7	10		000000000000000000100000	1	200.00	1	0.00	0.00	2		2		2							
H5509	017	0	1	04	01	H5509_017_0	5	8	Group 8	01	0000000000000001111100000000000100000		2		2			2		1	1	1	45	45	45	45	2		
H5509	018	0	1	04	01	H5509_018_0	5	5	Group 5	01	0000000000000000000000000111000000000		2		2			2		2		1		20		20			
H5509	018	0	1	04	01	H5509_018_0	5	4	Group 4	10		000000000000000010000000	2		1	0.00	50.00	2		2		1		45		45			
H5509	018	0	1	04	01	H5509_018_0	5	3	Group 3	11	0111101111111110000011110000111011111	000000100000000000001000	2		2			2		2		1		45		45			
H5509	018	0	1	04	01	H5509_018_0	5	2	Group 2	11	0000010000000000000000000000000000000	000000010010000000000000	2		1	0.00	0.00	2		2		2							
H5509	018	0	1	04	01	H5509_018_0	5	1	Group 1	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H5509	018	0	1	04	01	H5509_018_0	5	6	Group 6	10		000000000000000000100000	1	200.00	2			2		2		2							
H5509	018	0	1	04	01	H5509_018_0	5	7	Group 7	01	0000000000000001111100000000000100000		2		2			2		1	1	1	45	45	45	45	2		
H5509	019	0	1	04	01	H5509_019_0	7	1	Group 1	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H5509	019	0	1	04	01	H5509_019_0	7	2	Group 2	01	0000010000000000000000000000000000000		2		1	0.00	0.00	2		2		2							
H5509	019	0	1	04	01	H5509_019_0	7	3	Group 3	11	0111101111111110000011110000111011111	000000100000000000001000	2		2			2		2		1		45		45			
H5509	019	0	1	04	01	H5509_019_0	7	4	Group 4	10		000000000000000010000000	2		1	0.00	50.00	2		2		1		45		45			
H5509	019	0	1	04	01	H5509_019_0	7	5	Group 5	10		000000000000000000100000	1	200.00	2			2		2		2							
H5509	019	0	1	04	01	H5509_019_0	7	6	Group 6	01	0000000000000000000000000111000000000		2		2			2		2		1		20		20			
H5509	019	0	1	04	01	H5509_019_0	7	7	Group 7	01	0000000000000001111100000000000100000		2		2			2		1	1	1	45	45	45	45	2		
H5509	801	0	1	04	01	H5509_801_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5509	801	0	1	04	01	H5509_801_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5509	802	0	1	04	01	H5509_802_0	3	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5509	802	0	1	04	01	H5509_802_0	3	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5509	803	0	1	04	01	H5509_803_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5509	803	0	1	04	01	H5509_803_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5516	001	0	1	04	01	H5516_001_0	2	7	Group 7	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H5516	001	0	1	04	01	H5516_001_0	2	8	Group 8	01	0000000000100100000000100000000000000		2		1	35.00	45.00	2		2		2							
H5516	001	0	1	04	01	H5516_001_0	2	9	Group 9	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5516	001	0	1	04	01	H5516_001_0	2	1	Group 1	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H5516	001	0	1	04	01	H5516_001_0	2	10	Group 10	11	0000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H5516	001	0	1	04	01	H5516_001_0	2	11	Group 11	01	0000000000000000000000000000010000000		2		2			2		2		1		0		40			
H5516	001	0	1	04	01	H5516_001_0	2	6	Group 6	01	0000100000000000000000000000000000000		2		1	75.00	75.00	2		2		2							
H5516	001	0	1	04	01	H5516_001_0	2	13	Group 13	01	0000000000001000000000000000000000000		2		1	30.00	50.00	2		2		2							
H5516	001	0	1	04	01	H5516_001_0	2	2	Group 2	11	0111000111010010000000000000000001101	000001000000000000001010	2		1	50.00	50.00	2		2		2							
H5516	001	0	1	04	01	H5516_001_0	2	3	Group 3	11	0000000000000000000011000011001110010	000000000000000100000000	2		2			2		2		1		40		40			
H5516	001	0	1	04	01	H5516_001_0	2	4	Group 4	01	0000000000000001111100000000000000000		2		1	13.00	21.00	2		1	2	1		40		40	1	30.00	50.00
H5516	001	0	1	04	01	H5516_001_0	2	5	Group 5	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H5516	001	0	1	04	01	H5516_001_0	2	12	Group 12	01	0000010000000000000000000100000000000		2		2			2		2		1		50		50			
H5520	001	0	1	04	01	H5520_001_0	1	12	Group 0% or 20%	01	0000000000000001000000000000000000000		2		2			2		2		1		0		20			
H5520	001	0	1	04	01	H5520_001_0	1	11	Group $0	11	0000100000000000100000010000011100010	000000100000000110000000	2		1	0.00	0.00	2		2		2							
H5520	001	0	1	04	01	H5520_001_0	1	9	Group 20% or $200	01	0000000000000000000010000000000000000		2		1	200.00	200.00	2		2		1		20		20			
H5520	001	0	1	04	01	H5520_001_0	1	8	Group $15	01	0000010100000000000000000000000000000		2		1	15.00	15.00	2		2		2							
H5520	001	0	1	04	01	H5520_001_0	1	7	Group $100	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H5520	001	0	1	04	01	H5520_001_0	1	6	Group $0 - 20%	01	0000000000000000000000000001000000000		2		1	0.00	0.00	2		2		1		20		20			
H5520	001	0	1	04	01	H5520_001_0	1	5	Group $0 - $40	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	40.00	2		2		2							
H5520	001	0	1	04	01	H5520_001_0	1	4	Group 20%	01	0000000000000000011000000110100010000		2		2			2		2		1		20		20			
H5520	001	0	1	04	01	H5520_001_0	1	3	Group $50	01	0000000000100100000000100000000000000		2		1	50.00	50.00	2		2		2							
H5520	001	0	1	04	01	H5520_001_0	1	2	Group $35	01	0111000010000010000000000000000000000		2		1	35.00	35.00	2		2		2							
H5520	001	0	1	04	01	H5520_001_0	1	14	Group $0 with $250 Ben Max	10		000000000000000000000100	1	250.00	1	0.00	0.00	2		2		2							
H5520	001	0	1	04	01	H5520_001_0	1	13	Group $15 with $500 Ben Max	10		000010001000000000000000	1	500.00	1	15.00	15.00	2		2		2							
H5520	001	0	1	04	01	H5520_001_0	1	1	Group $20 - $40	01	0000001001011000000100000000000001001		2		1	20.00	40.00	2		2		2							
H5520	001	0	1	04	01	H5520_001_0	1	10	Group $175	01	0000000000000000000001000000000000000		2		1	175.00	175.00	2		2		2							
H5520	002	0	1	04	01	H5520_002_0	2	5	Group 20%	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5520	002	0	1	04	01	H5520_002_0	2	6	Group $0 - $40	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	40.00	2		2		2							
H5520	002	0	1	04	01	H5520_002_0	2	2	Group $35 - $50	01	0111000010100110000000100000000000000		2		1	35.00	50.00	2		2		2							
H5520	002	0	1	04	01	H5520_002_0	2	3	Group $0 with $250 Ben Max	10		000000000000000000000100	1	250.00	1	0.00	0.00	2		2		2							
H5520	002	0	1	04	01	H5520_002_0	2	4	Group 18%	01	0000000000000000011000000110000010000		2		2			2		2		1		18		18			
H5520	002	0	1	04	01	H5520_002_0	2	14	Group $15 with $500  Ben Max	10		000010001000000000000000	1	500.00	1	15.00	15.00	2		2		2							
H5520	002	0	1	04	01	H5520_002_0	2	13	Group $295	01	0000000000000000000000001000000000000		2		1	295.00	295.00	2		2		2							
H5520	002	0	1	04	01	H5520_002_0	2	12	Group $0 or 18%	01	0000000000000000000000000001000000000		2		1	0.00	0.00	2		2		1		18		18			
H5520	002	0	1	04	01	H5520_002_0	2	11	Group 0% - 18%	01	0000000000000001000000000000000000000		2		2			2		2		1		0		18			
H5520	002	0	1	04	01	H5520_002_0	2	10	Group $0	11	0000100000000000000000010000011100010	000000100000000110000000	2		1	0.00	0.00	2		2		2							
H5520	002	0	1	04	01	H5520_002_0	2	1	Group $20 - $40	01	0000001001011000100100000000000001001		2		1	20.00	40.00	2		2		2							
H5520	002	0	1	04	01	H5520_002_0	2	9	Group 18% or $200	01	0000000000000000000010000000000000000		2		1	200.00	200.00	2		2		1		18		18			
H5520	002	0	1	04	01	H5520_002_0	2	8	Group $15	01	0000010100000000000000000000000000000		2		1	15.00	15.00	2		2		2							
H5520	002	0	1	04	01	H5520_002_0	2	7	Group $175	01	0000000000000000000001000000000000000		2		1	175.00	175.00	2		2		2							
H5520	003	0	1	04	01	H5520_003_0	1	8	Group $15	01	0000010100000000000000000000000000000		2		1	15.00	15.00	2		2		2							
H5520	003	0	1	04	01	H5520_003_0	1	7	Group $100	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H5520	003	0	1	04	01	H5520_003_0	1	6	Group $0 or 20%	01	0000000000000000000000000001000000000		2		1	0.00	0.00	2		2		1		20		20			
H5520	003	0	1	04	01	H5520_003_0	1	5	Group $0 - $40	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	40.00	2		2		2							
H5520	003	0	1	04	01	H5520_003_0	1	4	Group 20%	01	0000000000000000011000000110100010000		2		2			2		2		1		20		20			
H5520	003	0	1	04	01	H5520_003_0	1	3	Group $50	01	0000000000100100000000100000000000000		2		1	50.00	50.00	2		2		2							
H5520	003	0	1	04	01	H5520_003_0	1	13	Group $15 with $500 Ben Max	10		000010001000000000000000	1	500.00	1	15.00	15.00	2		2		2							
H5520	003	0	1	04	01	H5520_003_0	1	11	Group $0	11	0000100000000000100000010000011100010	000000100000000110000000	2		1	0.00	0.00	2		2		2							
H5520	003	0	1	04	01	H5520_003_0	1	10	Group $175	01	0000000000000000000001000000000000000		2		1	175.00	175.00	2		2		2							
H5520	003	0	1	04	01	H5520_003_0	1	1	Group $20 - $40	01	0000001001011000000100000000000001001		2		1	20.00	40.00	2		2		2							
H5520	003	0	1	04	01	H5520_003_0	1	2	Group $35	01	0111000010000010000000000000000000000		2		1	35.00	35.00	2		2		2							
H5520	003	0	1	04	01	H5520_003_0	1	14	Group $0 with $250 Ben Max	10		000000000000000000000100	1	250.00	1	15.00	15.00	2		2		2							
H5520	003	0	1	04	01	H5520_003_0	1	9	Group 20% or $200	01	0000000000000000000010000000000000000		2		1	200.00	200.00	2		2		1		20		20			
H5520	003	0	1	04	01	H5520_003_0	1	12	Group 0% - 20%	01	0000000000000001000000000000000000000		2		2			2		2		1		0		20			
H5520	004	0	1	04	01	H5520_004_0	2	12	Group $0 or 18%	01	0000000000000000000000000001000000000		2		1	0.00	0.00	2		2		1		18		18			
H5520	004	0	1	04	01	H5520_004_0	2	11	Group 0% - 18%	01	0000000000000001000000000000000000000		2		2			2		2		1		0		18			
H5520	004	0	1	04	01	H5520_004_0	2	10	Group $0	11	0000100000000000000000010000011100010	000000100000000110000000	2		1	0.00	0.00	2		2		2							
H5520	004	0	1	04	01	H5520_004_0	2	1	Group $20 - $40	01	0000001001011000100100000000000001001		2		1	20.00	40.00	2		2		2							
H5520	004	0	1	04	01	H5520_004_0	2	9	Group 18% or $200	01	0000000000000000000010000000000000000		2		1	200.00	200.00	2		2		1		18		18			
H5520	004	0	1	04	01	H5520_004_0	2	8	Group $15	01	0000010100000000000000000000000000000		2		1	15.00	15.00	2		2		2							
H5520	004	0	1	04	01	H5520_004_0	2	7	Group $175	01	0000000000000000000001000000000000000		2		1	175.00	175.00	2		2		2							
H5520	004	0	1	04	01	H5520_004_0	2	6	Group $0 - $40	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	40.00	2		2		2							
H5520	004	0	1	04	01	H5520_004_0	2	5	Group 20%	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5520	004	0	1	04	01	H5520_004_0	2	4	Group 18%	01	0000000000000000011000000110000010000		2		2			2		2		1		18		18			
H5520	004	0	1	04	01	H5520_004_0	2	3	Group $0 with $250 Ben Max	10		000000000000000000000100	1	250.00	1	0.00	0.00	2		2		2							
H5520	004	0	1	04	01	H5520_004_0	2	13	Group $200	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H5520	004	0	1	04	01	H5520_004_0	2	14	Group $15 with $500 Ben Max	10		000010001000000000000000	1	500.00	1	15.00	15.00	2		2		2							
H5520	004	0	1	04	01	H5520_004_0	2	2	Group $35 - $50	01	0111000010100110000000100000000000000		2		1	35.00	50.00	2		2		2							
H5520	012	1	1	04	01	H5520_012_1	2	2	Group $35	01	0111000010000010000000000000000000000		2		1	35.00	35.00	2		2		2							
H5520	012	1	1	04	01	H5520_012_1	2	3	Group $50	01	0000000001110100000000100000000001001		2		1	50.00	50.00	2		2		2							
H5520	012	1	1	04	01	H5520_012_1	2	4	Group 20%	01	0000000000000000011011000110100010010		2		2			2		2		1		20		20			
H5520	012	1	1	04	01	H5520_012_1	2	5	Group $0 or 20%	01	0000000000000000000000000001000000000		2		1	0.00	0.00	2		2		1		20		20			
H5520	012	1	1	04	01	H5520_012_1	2	6	Group $380	01	0000000000000000000000001000000000000		2		1	380.00	380.00	2		2		2							
H5520	012	1	1	04	01	H5520_012_1	2	7	Group $0	11	0000100000000000000000010000011100000	000000100000000110000000	2		1	0.00	0.00	2		2		2							
H5520	012	1	1	04	01	H5520_012_1	2	13	Group $15	01	0000010000000000000000000000000000000		2		1	15.00	15.00	2		2		2							
H5520	012	1	1	04	01	H5520_012_1	2	9	Group 0% - 20%	01	0000000000000001000000000000000000000		2		2			2		2		1		0		20			
H5520	012	1	1	04	01	H5520_012_1	2	1	Group $20	01	0000000100000000100100000000000000000		2		1	20.00	20.00	2		2		2							
H5520	012	1	1	04	01	H5520_012_1	2	10	Group $20 with $250 Ben Max	10		000010001000000000000000	1	250.00	1	20.00	20.00	2		2		2							
H5520	012	1	1	04	01	H5520_012_1	2	11	Group $30 - $50	01	0000000000001000000000000000000000000		2		1	30.00	50.00	2		2		2							
H5520	012	1	1	04	01	H5520_012_1	2	12	Group $30	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H5520	012	1	1	04	01	H5520_012_1	2	8	Group $0 - $50	01	0000000000000000000000000000000000100		2		1	0.00	50.00	2		2		2							
H5520	012	2	1	04	01	H5520_012_2	2	1	Group $20	01	0000000100000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H5520	012	2	1	04	01	H5520_012_2	2	10	Group $0	11	0000100000000000000000010000011100000	000000100000000110000000	2		1	0.00	0.00	2		2		2							
H5520	012	2	1	04	01	H5520_012_2	2	11	Group $25	01	0000000000000000100100000000000000000		2		1	25.00	25.00	2		2		2							
H5520	012	2	1	04	01	H5520_012_2	2	12	Group $20 with $250 Ben Max	10		000010001000000000000000	1	250.00	1	20.00	20.00	2		2		2							
H5520	012	2	1	04	01	H5520_012_2	2	13	Group $30	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H5520	012	2	1	04	01	H5520_012_2	2	14	Group $30 - $50	01	0000000000001000000000000000000000000		2		1	30.00	50.00	2		2		2							
H5520	012	2	1	04	01	H5520_012_2	2	15	Group $15	01	0000010000000000000000000000000000000		2		1	15.00	15.00	2		2		2							
H5520	012	2	1	04	01	H5520_012_2	2	2	Group $35	01	0111000010000010000000000000000000000		2		1	35.00	35.00	2		2		2							
H5520	012	2	1	04	01	H5520_012_2	2	3	Group $50	01	0000000001110100000000100000000001001		2		1	50.00	50.00	2		2		2							
H5520	012	2	1	04	01	H5520_012_2	2	4	Group 20%	01	0000000000000000011011000110100000010		2		2			2		2		1		20		20			
H5520	012	2	1	04	01	H5520_012_2	2	5	Group $0 or 20%	01	0000000000000000000000000001000000000		2		1	0.00	0.00	2		2		1		20		20			
H5520	012	2	1	04	01	H5520_012_2	2	6	Group $415	01	0000000000000000000000001000000000000		2		1	415.00	415.00	2		2		2							
H5520	012	2	1	04	01	H5520_012_2	2	7	Group 18%	01	0000000000000000000000000000000010000		2		2			2		2		1		18		18			
H5520	012	2	1	04	01	H5520_012_2	2	8	Group $0 - $50	01	0000000000000000000000000000000000100		2		1	0.00	50.00	2		2		2							
H5520	012	2	1	04	01	H5520_012_2	2	9	Group 0% - 20%	01	0000000000000001000000000000000000000		2		2			2		2		1		0		20			
H5520	012	3	1	04	01	H5520_012_3	2	1	Group $20	01	0000000100000000100100000000000000000		2		1	20.00	20.00	2		2		2							
H5520	012	3	1	04	01	H5520_012_3	2	8	Group $0 - $50	01	0000000000000000000000000000000000100		2		1	0.00	50.00	2		2		2							
H5520	012	3	1	04	01	H5520_012_3	2	7	Group $0	11	0000100000000000000000010000011100000	000000100000000110000000	2		1	0.00	0.00	2		2		2							
H5520	012	3	1	04	01	H5520_012_3	2	6	Group $375	01	0000000000000000000000001000000000000		2		1	375.00	375.00	2		2		2							
H5520	012	3	1	04	01	H5520_012_3	2	5	Group $0 or 20%	01	0000000000000000000000000001000000000		2		1	0.00	0.00	2		2		1		20		20			
H5520	012	3	1	04	01	H5520_012_3	2	4	Group 20%	01	0000000000000000011011000110100010010		2		2			2		2		1		20		20			
H5520	012	3	1	04	01	H5520_012_3	2	10	Group $20 with $250 Ben Max	10		000010001000000000000000	1	250.00	1	20.00	20.00	2		2		2							
H5520	012	3	1	04	01	H5520_012_3	2	2	Group $35	01	0111000010000010000000000000000000000		2		1	35.00	35.00	2		2		2							
H5520	012	3	1	04	01	H5520_012_3	2	13	Group $15	01	0000010000000000000000000000000000000		2		1	15.00	15.00	2		2		2							
H5520	012	3	1	04	01	H5520_012_3	2	12	Group $30 - $50	01	0000000000001000000000000000000000000		2		1	30.00	50.00	2		2		2							
H5520	012	3	1	04	01	H5520_012_3	2	11	Group $30	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H5520	012	3	1	04	01	H5520_012_3	2	9	Group 0% - 20%	01	0000000000000001000000000000000000000		2		2			2		2		1		0		20			
H5520	012	3	1	04	01	H5520_012_3	2	3	Group $50	01	0000000001110100000000100000000001001		2		1	50.00	50.00	2		2		2							
H5520	014	0	1	04	01	H5520_014_0	2	9	Group 0% - 20%	01	0000000000000001000000000000000000000		2		2			2		2		1		0		20			
H5520	014	0	1	04	01	H5520_014_0	2	7	Group $0	11	0000100000000000000000010000011100000	000000100000000110000000	2		1	0.00	0.00	2		2		2							
H5520	014	0	1	04	01	H5520_014_0	2	8	Group $0 - $50	01	0000000000000000000000000000000000100		2		1	0.00	50.00	2		2		2							
H5520	014	0	1	04	01	H5520_014_0	2	6	Group $380	01	0000000000000000000000001000000000000		2		1	380.00	380.00	2		2		2							
H5520	014	0	1	04	01	H5520_014_0	2	5	Group $0 or 20%	01	0000000000000000000000000001000000000		2		1	0.00	0.00	2		2		1		20		20			
H5520	014	0	1	04	01	H5520_014_0	2	4	Group 20%	01	0000000000000000011011000110100010010		2		2			2		2		1		20		20			
H5520	014	0	1	04	01	H5520_014_0	2	3	Group $50	01	0000000001110100000000100000000001001		2		1	50.00	50.00	2		2		2							
H5520	014	0	1	04	01	H5520_014_0	2	2	Group $35	01	0111000010000010000000000000000000000		2		1	35.00	35.00	2		2		2							
H5520	014	0	1	04	01	H5520_014_0	2	12	Group $15	01	0000010000000000000000000000000000000		2		1	15.00	15.00	2		2		2							
H5520	014	0	1	04	01	H5520_014_0	2	11	Group $30 - $50	01	0000000000001000000000000000000000000		2		1	30.00	50.00	2		2		2							
H5520	014	0	1	04	01	H5520_014_0	2	10	Group $30	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H5520	014	0	1	04	01	H5520_014_0	2	1	Group $20	01	0000000100000000100100000000000000000		2		1	20.00	20.00	2		2		2							
H5520	015	1	1	04	01	H5520_015_1	2	7	Group $0	11	0000100000000000000000010000011100010	000000100000000110000000	2		1	0.00	0.00	2		2		2							
H5520	015	1	1	04	01	H5520_015_1	2	2	Group $35	01	0111000010000010000000000000000000000		2		1	35.00	35.00	2		2		2							
H5520	015	1	1	04	01	H5520_015_1	2	3	Group $50	01	0000000001110100000000100000000001001		2		1	50.00	50.00	2		2		2							
H5520	015	1	1	04	01	H5520_015_1	2	8	Group $0 - $50	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	50.00	2		2		2							
H5520	015	1	1	04	01	H5520_015_1	2	9	Group 0% - 20%	01	0000000000000001000000000000000000000		2		2			2		2		1		0		20			
H5520	015	1	1	04	01	H5520_015_1	2	14	Group $15	01	0000010000000000000000000000000000000		2		1	15.00	15.00	2		2		2							
H5520	015	1	1	04	01	H5520_015_1	2	4	Group 20%	01	0000000000000000011011000110100010000		2		2			2		2		1		20		20			
H5520	015	1	1	04	01	H5520_015_1	2	12	Group $30	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H5520	015	1	1	04	01	H5520_015_1	2	11	Group $0 with $250 Ben Max	10		000000000000000000000100	1	250.00	1	0.00	0.00	2		2		2							
H5520	015	1	1	04	01	H5520_015_1	2	10	Group $20 with $250 Ben Max	10		000010001000000000000000	1	250.00	1	20.00	20.00	2		2		2							
H5520	015	1	1	04	01	H5520_015_1	2	1	Group $20	01	0000000100000000100100000000000000000		2		1	20.00	20.00	2		2		2							
H5520	015	1	1	04	01	H5520_015_1	2	6	Group $200	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H5520	015	1	1	04	01	H5520_015_1	2	5	Group $0 or 20%	01	0000000000000000000000000001000000000		2		1	0.00	0.00	2		2		1		20		20			
H5520	015	1	1	04	01	H5520_015_1	2	13	Group $30 - $50	01	0000000000001000000000000000000000000		2		1	30.00	50.00	2		2		2							
H5520	015	2	1	04	01	H5520_015_2	2	13	Group $30 - $50	01	0000000000001000000000000000000000000		2		1	30.00	50.00	2		2		2							
H5520	015	2	1	04	01	H5520_015_2	2	12	Group $30	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H5520	015	2	1	04	01	H5520_015_2	2	11	Group $0 with $250 Ben Max	10		000000000000000000000100	1	250.00	1	0.00	0.00	2		2		2							
H5520	015	2	1	04	01	H5520_015_2	2	9	Group 0% - 20%	01	0000000000000001000000000000000000000		2		2			2		2		1		0		20			
H5520	015	2	1	04	01	H5520_015_2	2	8	Group $0 - $50	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	50.00	2		2		2							
H5520	015	2	1	04	01	H5520_015_2	2	7	Group $0	11	0000100000000000000000010000011100010	000000100000000110000000	2		1	0.00	0.00	2		2		2							
H5520	015	2	1	04	01	H5520_015_2	2	6	Group $395	01	0000000000000000000000001000000000000		2		1	395.00	395.00	2		2		2							
H5520	015	2	1	04	01	H5520_015_2	2	5	Group $0 or 20%	01	0000000000000000000000000001000000000		2		1	0.00	0.00	2		2		1		20		20			
H5520	015	2	1	04	01	H5520_015_2	2	4	Group 20%	01	0000000000000000011011000110100010000		2		2			2		2		1		20		20			
H5520	015	2	1	04	01	H5520_015_2	2	3	Group $50	01	0000000001110100000000100000000001001		2		1	50.00	50.00	2		2		2							
H5520	015	2	1	04	01	H5520_015_2	2	10	Group $20 with $250 Ben Max	10		000010001000000000000000	1	250.00	1	20.00	20.00	2		2		2							
H5520	015	2	1	04	01	H5520_015_2	2	14	Group $15	01	0000010000000000000000000000000000000		2		1	15.00	15.00	2		2		2							
H5520	015	2	1	04	01	H5520_015_2	2	2	Group $35	01	0111000010000010000000000000000000000		2		1	35.00	35.00	2		2		2							
H5520	015	2	1	04	01	H5520_015_2	2	1	Group $20	01	0000000100000000100100000000000000000		2		1	20.00	20.00	2		2		2							
H5520	807	0	1	04	01	H5520_807_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5520	807	0	1	04	01	H5520_807_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5520	808	0	1	04	01	H5520_808_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5520	808	0	1	04	01	H5520_808_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5520	809	0	1	04	01	H5520_809_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5520	809	0	1	04	01	H5520_809_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5521	012	0	1	04	01	H5521_012_0	5	5	Tier 5	10		000000000000000000100000	1	150.00	2			2		2		2							
H5521	012	0	1	04	01	H5521_012_0	5	4	Tier 4	10		000000000000000010000000	2		2			2		2		2							
H5521	012	0	1	04	01	H5521_012_0	5	3	Tier 3	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5521	012	0	1	04	01	H5521_012_0	5	2	Tier 2	01	0000000000000000000000001000000000000		2		1	300.00	300.00	2		2		2							
H5521	012	0	1	04	01	H5521_012_0	5	1	Tier 1	11	0111111111111111111111110111011111111	000000000000000100001010	2		2			2		2		1		25		25			
H5521	013	0	1	04	01	H5521_013_0	5	5	Tier 5	10		000000000000000000100000	1	150.00	2			2		2		2							
H5521	013	0	1	04	01	H5521_013_0	5	2	Tier 2	01	0000000000000000000000001000000000000		2		1	300.00	300.00	2		2		2							
H5521	013	0	1	04	01	H5521_013_0	5	1	Tier 1	11	0111111111111111111111110111011111111	000000000000000100001010	2		2			2		2		1		30		30			
H5521	013	0	1	04	01	H5521_013_0	5	4	Tier 4	10		000000000000000010000000	2		2			2		2		2							
H5521	013	0	1	04	01	H5521_013_0	5	3	Tier 3	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5521	015	0	1	04	01	H5521_015_0	10	4	Tier 4	10		000000000000000010000000	2		2			2		2		2							
H5521	015	0	1	04	01	H5521_015_0	10	1	Tier 1	11	0111111111111111111111110111011111111	000000000000000100001010	2		2			2		2		1		50		50			
H5521	015	0	1	04	01	H5521_015_0	10	2	Tier 2	01	0000000000000000000000001000000000000		2		1	300.00	300.00	2		2		2							
H5521	015	0	1	04	01	H5521_015_0	10	3	Tier 3	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5521	016	0	1	04	01	H5521_016_0	4	1	Tier 1	11	0111111111111111111111110111011111111	000000000000000100001010	2		2			2		2		1		30		30			
H5521	016	0	1	04	01	H5521_016_0	4	2	Tier 2	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H5521	016	0	1	04	01	H5521_016_0	4	4	Tier 4	10		000000000000000010000000	2		2			2		2		2							
H5521	016	0	1	04	01	H5521_016_0	4	3	Tier 3	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5521	020	0	1	04	01	H5521_020_0	5	4	Tier 4	10		000000000000000010000000	2		2			2		2		2							
H5521	020	0	1	04	01	H5521_020_0	5	3	Tier 3	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5521	020	0	1	04	01	H5521_020_0	5	2	Tier 2	01	0000000000000000000000001000000000000		2		1	300.00	300.00	2		2		2							
H5521	020	0	1	04	01	H5521_020_0	5	1	Tier 1	11	0111111111111111111111110111011111111	000000000000000100001010	2		2			2		2		1		25		25			
H5521	022	0	1	04	01	H5521_022_0	7	7	Tier 7	10		000000000000000000000001	1	300.00	2			2		2		2							
H5521	022	0	1	04	01	H5521_022_0	7	2	Tier 2	01	0000000000000000000000001000000000000		2		1	400.00	400.00	2		2		2							
H5521	022	0	1	04	01	H5521_022_0	7	4	Tier 4	10		000000000000000000100000	1	500.00	2			2		2		2							
H5521	022	0	1	04	01	H5521_022_0	7	5	Tier 5	10		000000000000000000000100	1	125.00	2			2		2		2							
H5521	022	0	1	04	01	H5521_022_0	7	6	Tier 6	10		000000000000000010000000	2		2			2		2		2							
H5521	022	0	1	04	01	H5521_022_0	7	3	Tier 3	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5521	022	0	1	04	01	H5521_022_0	7	1	Tier 1	11	0111111111111111111111110111011111111	000000000000000100001010	2		2			2		2		1		40		40			
H5521	027	0	1	04	01	H5521_027_0	4	4		10		000000000000000010000000	2		2			2		2		2							
H5521	027	0	1	04	01	H5521_027_0	4	3		01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5521	027	0	1	04	01	H5521_027_0	4	2	Tier 2	01	0000000000000000000000001000000000000		2		1	300.00	300.00	2		2		2							
H5521	027	0	1	04	01	H5521_027_0	4	1	Tier 1	11	0111111111111111111111110111011111111	000000000000000100001010	2		2			2		2		1		50		50			
H5521	028	0	1	04	01	H5521_028_0	11	4	Tier 4	10		000000000000000000010001	1	500.00	2			2		2		2							
H5521	028	0	1	04	01	H5521_028_0	11	5	Tier 5	10		000000000000000000000100	1	125.00	2			2		2		2							
H5521	028	0	1	04	01	H5521_028_0	11	3	Tier 3	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5521	028	0	1	04	01	H5521_028_0	11	2	Tier 2	01	0000000000000000000000001000000000000		2		1	275.00	275.00	2		2		2							
H5521	028	0	1	04	01	H5521_028_0	11	1	Tier 1	11	0111111111111111111111110111011111111	000000000000000110101010	2		2			2		2		1		40		40			
H5521	033	0	1	04	01	H5521_033_0	5	4	Tier 4	10		000000000000000010000000	2		2			2		2		2							
H5521	033	0	1	04	01	H5521_033_0	5	3	Tier 3	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5521	033	0	1	04	01	H5521_033_0	5	2	Tier 2	01	0000000000000000000000001000000000000		2		1	300.00	300.00	2		2		2							
H5521	033	0	1	04	01	H5521_033_0	5	1	Tier 1	11	0111111111111111111111110111011111111	000000000000000100001010	2		2			2		2		1		30		30			
H5521	037	0	1	04	01	H5521_037_0	7	3	Tier 3	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5521	037	0	1	04	01	H5521_037_0	7	4	Tier 4	10		000000000000000010000000	2		2			2		2		2							
H5521	037	0	1	04	01	H5521_037_0	7	2	Tier 2	01	0000000000000000000000001000000000000		2		1	300.00	300.00	2		2		2							
H5521	037	0	1	04	01	H5521_037_0	7	1	Tier 1	11	0111111111111111111111110111011111111	000000000000000100001010	2		2			2		2		1		40		40			
H5521	040	0	1	04	01	H5521_040_0	7	1	Tier 1	11	0111111111111111111111110111011111111	000000000000000100001010	2		2			2		2		1		40		40			
H5521	040	0	1	04	01	H5521_040_0	7	2	Tier 2	01	0000000000000000000000001000000000000		2		1	300.00	300.00	2		2		2							
H5521	040	0	1	04	01	H5521_040_0	7	3	Tier 3	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5521	040	0	1	04	01	H5521_040_0	7	4	Tier 4	10		000000000000000010000000	2		2			2		2		2							
H5521	040	0	1	04	01	H5521_040_0	7	5	Tier 5	10		000000000000000000000100	1	300.00	2			2		2		2							
H5521	040	0	1	04	01	H5521_040_0	7	6	Tier 6	10		000000000000000000000001	1	1000.00	2			2		2		2							
H5521	052	0	1	04	01	H5521_052_0	6	1	Tier 1	11	0111111111111111111111110111011111111	000000000000000100001010	2		2			2		2		1		20		20			
H5521	052	0	1	04	01	H5521_052_0	6	2	Tier 2	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H5521	052	0	1	04	01	H5521_052_0	6	5	Tier 5	10		000000000000000000100100	1	150.00	2			2		2		2							
H5521	052	0	1	04	01	H5521_052_0	6	4	Tier 4	10		000000000000000010000000	2		2			2		2		2							
H5521	052	0	1	04	01	H5521_052_0	6	3	Tier 3	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5521	053	0	1	04	01	H5521_053_0	4	1	Tier 1	11	0111111111111111111111110111011111111	000000000000000100001010	2		2			2		2		1		40		40			
H5521	053	0	1	04	01	H5521_053_0	4	2	Tier 2	01	0000000000000000000000001000000000000		2		1	300.00	300.00	2		2		2							
H5521	053	0	1	04	01	H5521_053_0	4	3		01	0000000000000000000000000000100000000		2		2			2		2		1		30		30			
H5521	053	0	1	04	01	H5521_053_0	4	4		10		000000000000000010000000	2		2			2		2		2							
H5521	055	0	1	04	01	H5521_055_0	4	1	Tier 1	11	0111111111111111111111110111011111111	000000000000000100001010	2		2			2		2		1		40		40			
H5521	055	0	1	04	01	H5521_055_0	4	2	Tier 2	01	0000000000000000000000001000000000000		2		1	400.00	400.00	2		2		2							
H5521	055	0	1	04	01	H5521_055_0	4	3		01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5521	055	0	1	04	01	H5521_055_0	4	4		10		000000000000000010000000	2		2			2		2		2							
H5521	056	0	1	04	01	H5521_056_0	4	4		10		000000000000000010000000	2		2			2		2		2							
H5521	056	0	1	04	01	H5521_056_0	4	3		01	0000000000000000000000000000100000000		2		1	30.00	30.00	2		2		2							
H5521	056	0	1	04	01	H5521_056_0	4	2	Tier 2	01	0000000000000000000000001000000000000		2		1	300.00	300.00	2		2		2							
H5521	056	0	1	04	01	H5521_056_0	4	1	Tier 1	11	0111111111111111111111110111011111111	000000000000000100001010	2		2			2		2		1		40		40			
H5521	057	0	1	04	01	H5521_057_0	8	4	Tier 4	10		000000000000000010000000	2		2			2		2		2							
H5521	057	0	1	04	01	H5521_057_0	8	3	Tier 3	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5521	057	0	1	04	01	H5521_057_0	8	2	Tier 2	01	0000000000000000000000001000000000000		2		1	275.00	275.00	2		2		2							
H5521	057	0	1	04	01	H5521_057_0	8	1	Tier 1	11	0111111111111111111111110111011111111	000000000000000100001010	2		2			2		2		1		40		40			
H5521	058	0	1	04	01	H5521_058_0	4	4	Tier 4	10		000000000000000010000000	2		2			2		2		2							
H5521	058	0	1	04	01	H5521_058_0	4	5	Tier 5	10		000000000000000000100000	1	150.00	2			2		2		2							
H5521	058	0	1	04	01	H5521_058_0	4	3	Tier 3	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5521	058	0	1	04	01	H5521_058_0	4	2	Tier 2	01	0000000000000000000000001000000000000		2		1	350.00	350.00	2		2		2							
H5521	058	0	1	04	01	H5521_058_0	4	1	Tier 1	11	0111111111111111111111110111011111111	000000000000000100001010	2		2			2		2		1		40		40			
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H5521	059	0	1	04	01	H5521_059_0	5	4	Tier 4	10		000000000000000010000000	2		2			2		2		2							
H5521	059	0	1	04	01	H5521_059_0	5	5	Tier 5	10		000000000000000000100000	1	150.00	2			2		2		2							
H5521	059	0	1	04	01	H5521_059_0	5	2	Tier 2	01	0000000000000000000000001000000000000		2		1	350.00	350.00	2		2		2							
H5521	059	0	1	04	01	H5521_059_0	5	1	Tier 1	11	0111111111111111111111110111011111111	000000000000000100001010	2		2			2		2		1		40		40			
H5521	060	0	1	04	01	H5521_060_0	4	3	Tier 3	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5521	060	0	1	04	01	H5521_060_0	4	4	Tier 4	10		000000000000000010000000	2		2			2		2		2							
H5521	060	0	1	04	01	H5521_060_0	4	5	Tier 5	10		000000000000000000100000	1	150.00	2			2		2		2							
H5521	060	0	1	04	01	H5521_060_0	4	2	Tier 2	01	0000000000000000000000001000000000000		2		1	350.00	350.00	2		2		2							
H5521	060	0	1	04	01	H5521_060_0	4	1	Tier 1	11	0111111111111111111111110111011111111	000000000000000100001010	2		2			2		2		1		40		40			
H5521	076	0	1	04	01	H5521_076_0	4	4	Tier 4	10		000000000000000010000000	2		2			2		2		2							
H5521	076	0	1	04	01	H5521_076_0	4	5	Tier 5	10		000000000000000000000100	1	300.00	2			2		2		2							
H5521	076	0	1	04	01	H5521_076_0	4	6	Tier 6	10		000000000000000000000001	1	1000.00	2			2		2		2							
H5521	076	0	1	04	01	H5521_076_0	4	2	Tier 2	01	0000000000000000000000001000000000000		2		1	300.00	300.00	2		2		2							
H5521	076	0	1	04	01	H5521_076_0	4	3	Tier 3	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5521	076	0	1	04	01	H5521_076_0	4	1	Tier 1	11	0111111111111111111111110111011111111	000000000000000100001010	2		2			2		2		1		40		40			
H5521	077	0	1	04	01	H5521_077_0	5	2	Tier 2	01	0000000000000000000000001000000000000		2		1	300.00	300.00	2		2		2							
H5521	077	0	1	04	01	H5521_077_0	5	3	Tier 3	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5521	077	0	1	04	01	H5521_077_0	5	4	Tier 4	10		000000000000000010000000	2		2			2		2		2							
H5521	077	0	1	04	01	H5521_077_0	5	5	Tier 5	10		000000000000000000000100	1	300.00	2			2		2		2							
H5521	077	0	1	04	01	H5521_077_0	5	1	Tier 1	11	0111111111111111111111110111011111111	000000000000000100001010	2		2			2		2		1		40		40			
H5521	077	0	1	04	01	H5521_077_0	5	7		10		000000000000000000100000	1	150.00	2			2		2		2							
H5521	077	0	1	04	01	H5521_077_0	5	6	Tier 6	10		000000000000000000000001	1	1000.00	2			2		2		2							
H5521	081	0	1	04	01	H5521_081_0	3	7	$45	01	0000000000000000000000000000000001001		2		1	45.00	45.00	2		2		2							
H5521	081	0	1	04	01	H5521_081_0	3	6	$35	01	0000001000000000000000000000000000000		2		1	35.00	35.00	2		2		2							
H5521	081	0	1	04	01	H5521_081_0	3	5	$0	11	0000000000000000000000000000011100000	000000000000000110001000	2		2			2		2		2							
H5521	081	0	1	04	01	H5521_081_0	3	4	30%/$55	01	0000000000000000000000000010000000000		2		1	55.00	55.00	2		2		1		30		30			
H5521	081	0	1	04	01	H5521_081_0	3	3	30%	01	0000000000000000001000000100000000000		2		2			2		2		1		30		30			
H5521	081	0	1	04	01	H5521_081_0	3	2	25%	01	0000000000000001110111110000000000000		2		2			2		2		1		25		25			
H5521	081	0	1	04	01	H5521_081_0	3	11	$75 Allowance	10		000000000000000000000100	1	75.00	2			2		2		2							
H5521	081	0	1	04	01	H5521_081_0	3	10	$120 allowance	10		000000000000000000100000	1	120.00	2			2		2		2							
H5521	081	0	1	04	01	H5521_081_0	3	1	20%	01	0000110100000000000000000001100010010		2		2			2		2		1		20		20			
H5521	081	0	1	04	01	H5521_081_0	3	9	$200	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H5521	081	0	1	04	01	H5521_081_0	3	8	$55	11	0111000011111110000000000000000000100	000000000000000000000010	2		1	55.00	55.00	2		2		2							
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H5522	001	0	1	04	01	H5522_001_0	7	11	30% PREVENTIVE DENTAL	10		000000000000000000100000	1	1000.00	2			1	100.00	2		1		30		30			
H5522	001	0	1	04	01	H5522_001_0	7	10	HEARING AIDS 50%	10		000000000000000000000001	1	1000.00	2			2		2		1		50		50			
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H5522	002	0	1	04	01	H5522_002_0	4	5	0-30%	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
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H5522	002	0	1	04	01	H5522_002_0	4	2	45%	01	0000100000100100000000100000000000000		2		2			2		2		1		45		45			
H5522	002	0	1	04	01	H5522_002_0	4	9	HEARING AIDS	10		000000000000000000000001	1	1000.00	2			2		2		1		50		50			
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H5522	002	0	1	04	01	H5522_002_0	4	10	NO COST SHARING	10		000000000000000000000100	1	150.00	2			2		2		2							
H5522	002	0	1	04	01	H5522_002_0	4	7	Preventive Dental	10		000000000000000000100000	1	1000.00	2			1	100.00	2		1		30		30			
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H5522	005	0	1	04	01	H5522_005_0	4	1	30%	11	0111001111011011111111010111100011111	000001100000000000001010	2		2			2		2		1		30		30			
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H5522	005	0	1	04	01	H5522_005_0	4	6	$50	10		000000000000000010000000	2		1	50.00	50.00	2		2		2							
H5522	005	0	1	04	01	H5522_005_0	4	5	$350	01	0000000000000000000000001000000000000		2		1	350.00	350.00	2		2		2							
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H5522	005	0	1	04	01	H5522_005_0	4	3	NO COST SHARING	01	0000010000000000000000000000000000000		2		2			2		2		2							
H5522	013	0	1	04	01	H5522_013_0	3	7	PREVENTIVE DENTAL	10		000000000000000000100000	1	150.00	2			2		2		2							
H5522	013	0	1	04	01	H5522_013_0	3	6	NON-MEDICARE COVERED EYEWARE	10		000000000000000000000100	1	150.00	2			2		2		2							
H5522	013	0	1	04	01	H5522_013_0	3	5	NO COST SHARE	01	0000010000000000000000000000000000000		2		2			2		2		2							
H5522	013	0	1	04	01	H5522_013_0	3	4	$50	10		000000000000000010000000	2		1	50.00	50.00	2		2		2							
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H5522	014	0	1	04	01	H5522_014_0	4	2	30%	01	0000000000000000000000001000100000000		2		2			2		2		1		30		30			
H5522	014	0	1	04	01	H5522_014_0	4	5	NO COST SHARING	01	0000010000000000000000000000000000000		2		2			2		2		2							
H5522	014	0	1	04	01	H5522_014_0	4	6	0-20%	01	0000000000000000000000000000010000000		2		2			2		2		1		0		20			
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H5526	004	0	1	04	01	H5526_004_0	6	5	Ambulance	01	0000000000000000000000001000000000000		2		1	125.00	125.00	2		2		2							
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H5526	014	0	1	04	01	H5526_014_0	6	5	Ambulance	01	0000000000000000000000001000000000000		2		1	125.00	125.00	2		2		2							
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H5526	014	0	1	04	01	H5526_014_0	6	3	50% Group	01	0000100000100100000000100111000000000		2		2			2		2		1		50		50			
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H5526	016	0	1	04	01	H5526_016_0	7	1	$0 Group	10		000000000000000010000000	2		2			2		2		2							
H5526	016	0	1	04	01	H5526_016_0	7	4	Ambulance	01	0000000000000000000000001000000000000		2		1	175.00	175.00	2		2		2							
H5526	017	0	1	04	01	H5526_017_0	8	3	50% Group	01	0000100000100100000000100111000000000		2		2			2		2		1		50		50			
H5526	017	0	1	04	01	H5526_017_0	8	4	Ambulance	01	0000000000000000000000001000000000000		2		1	175.00	175.00	2		2		2							
H5526	017	0	1	04	01	H5526_017_0	8	1	$0 Group	10		000000000000000010000000	2		2			2		2		2							
H5526	017	0	1	04	01	H5526_017_0	8	2	30% Group	11	0111011111011011111111010000111111111	000001100000000110001000	2		2			2		2		1		30		30			
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H5528	001	0	1	04	01	H5528_001_0	3	2	$0 Cost Sharing	01	0000010000000000000000000000001000000		2		1	0.00	0.00	2		2		2							
H5528	001	0	1	04	01	H5528_001_0	3	1	50% Cost Sharing w/o sep ofc visit copay	11	0111101111111110000011110111110011011	000001100000000110101100	2		2			2		2		1		50		50			
H5528	001	0	1	04	01	H5528_001_0	3	3	$75 Cost Sharing	01	0000000000000000000000001000000000000		2		1	75.00	75.00	2		2		2							
H5528	001	0	1	04	01	H5528_001_0	3	4	50% Cost Sharing w/sep ofc visit copay	01	0000000000000001111100000000000100100		2		2			2		1	1	1	50	50	50	50	2		
H5528	004	0	1	04	01	H5528_004_0	3	1	50% Cost Sharing w/o sep ofc visit copay	11	0111101111111110000111110111110011011	000001100000000110101100	2		2			2		2		1		50		50			
H5528	004	0	1	04	01	H5528_004_0	3	2	$0 Cost Sharing	01	0000010000000000000000000000001000000		2		1	0.00	0.00	2		2		2							
H5528	004	0	1	04	01	H5528_004_0	3	3	$75 Cost Sharing	01	0000000000000000000000001000000000000		2		1	75.00	75.00	2		2		2							
H5528	004	0	1	04	01	H5528_004_0	3	4	50% Cost Sharing w/sep ofc visit copay	01	0000000000000001111100000000000100100		2		2			2		1	1	1	50	50	50	50	2		
H5528	009	0	1	04	01	H5528_009_0	3	3	$75 Cost Sharing	01	0000000000000000000000001000000000000		2		1	75.00	75.00	2		2		2							
H5528	009	0	1	04	01	H5528_009_0	3	4	50% Cost Sharing w/sep ofc visit copay	01	0000000000000001111100000000000100100		2		2			2		1	1	1	50	50	50	50	2		
H5528	009	0	1	04	01	H5528_009_0	3	1	50% Cost Sharing w/o sep ofc visit copay	11	0111101111111110000011110111110011011	000001100000000110101100	2		2			2		2		1		50		50			
H5528	009	0	1	04	01	H5528_009_0	3	2	$0 Cost Sharing	01	0000010000000000000000000000001000000		2		1	0.00	0.00	2		2		2							
H5528	018	0	1	04	01	H5528_018_0	8	1	50% Cost Sharing w/o sep ofc visit copay	11	0111101111111110000011110111110011011	000001100000000010101100	2		2			2		2		1		50		50			
H5528	018	0	1	04	01	H5528_018_0	8	2	OTC Benefit	10		000000000100000000000000	1	20.00	2			2		2		2							
H5528	018	0	1	04	01	H5528_018_0	8	3	20% Cost Sharing	01	0000000000000000000000001000000000000		2		2			2		2		1		20		20			
H5528	018	0	1	04	01	H5528_018_0	8	4	$0 Cost Sharing	01	0000010000000000000000000000001000000		2		2			2		2		2							
H5528	018	0	1	04	01	H5528_018_0	8	5	50% Cost Sharing w/sep ofc visit copay	01	0000000000000001111100000000000100100		2		2			2		1	1	1	50	50	50	50	2		
H5528	022	0	1	04	01	H5528_022_0	5	2	$0 Cost Sharing	01	0000010000000000000000000000001000000		2		1	0.00	0.00	2		2		2							
H5528	022	0	1	04	01	H5528_022_0	5	1	50% Cost Sharing w/o sep ofc visit copay	11	0111101111111110000111110111110011011	000001100000000110101110	2		2			2		2		1		50		50			
H5528	022	0	1	04	01	H5528_022_0	5	3	50% Cost Sharing w/ sep ofc visit copay	01	0000000000000001111100000000000100100		2		2			2		1	1	1	50	50	50	50	2		
H5528	022	0	1	04	01	H5528_022_0	5	5	$150 Cost Sharing	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H5528	022	0	1	04	01	H5528_022_0	5	4	50% Cost Sharing up to $1000	10		000000000000000000000001	1	1000.00	2			2		2		1		50		50			
H5528	023	0	1	04	01	H5528_023_0	5	1	50% Cost Sharing w/o sep ofc visit copay	11	0111101111111110000011110111110011011	000001100000000110101110	2		2			2		2		1		50		50			
H5528	023	0	1	04	01	H5528_023_0	5	2	$0 Cost Sharing	01	0000010000000000000000000000001000000		2		1	0.00	0.00	2		2		2							
H5528	023	0	1	04	01	H5528_023_0	5	4	50% Cost Sharing up to $1000	10		000000000000000000000001	1	1000.00	2			2		2		1		50		50			
H5528	023	0	1	04	01	H5528_023_0	5	3	50% Cost Sharing w/ sep ofc visit copay	01	0000000000000001111100000000000100100		2		2			2		1	1	1	50	50	50	50	2		
H5528	023	0	1	04	01	H5528_023_0	5	5	$150 Cost Sharing	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H5528	024	0	1	04	01	H5528_024_0	5	2	$0 Cost Sharing	01	0000010000000000000000000000001000000		2		1	0.00	0.00	2		2		2							
H5528	024	0	1	04	01	H5528_024_0	5	1	50% Cost Sharing w/o sep ofc visit copay	11	0111101111111110000011110111110011011	000001100000000110101110	2		2			2		2		1		50		50			
H5528	024	0	1	04	01	H5528_024_0	5	3	50% Cost Sharing w/ sep ofc visit copay	01	0000000000000001111100000000000100100		2		2			2		1	1	1	50	50	50	50	2		
H5528	024	0	1	04	01	H5528_024_0	5	5	$150 Cost Sharing	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H5528	024	0	1	04	01	H5528_024_0	5	4	50% Cost Sharing up to $1000	10		000000000000000000000001	1	1000.00	2			2		2		1		50		50			
H5528	025	0	1	04	01	H5528_025_0	5	1	50% Cost Sharing w/o sep ofc visit copay	11	0111101111111110000111110111110011011	000001100000000110101110	2		2			2		2		1		50		50			
H5528	025	0	1	04	01	H5528_025_0	5	2	$0 Cost Sharing	01	0000010000000000000000000000001000000		2		1	0.00	0.00	2		2		2							
H5528	025	0	1	04	01	H5528_025_0	5	3	50% Cost Sharing w/ sep ofc visit copay	01	0000000000000001111100000000000100100		2		2			2		1	1	1	50	50	50	50	2		
H5528	025	0	1	04	01	H5528_025_0	5	4	50% Cost Sharing up to $1000	10		000000000000000000000001	1	1000.00	2			2		2		1		50		50			
H5528	025	0	1	04	01	H5528_025_0	5	5	$150 Cost Sharing	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H5528	026	0	1	04	01	H5528_026_0	5	1	50% Cost Sharing w/o sep ofc visit copay	11	0111101111111110000011110111110011011	000001100000000110101110	2		2			2		2		1		50		50			
H5528	026	0	1	04	01	H5528_026_0	5	3	50% Cost Sharing w/ sep ofc visit copay	01	0000000000000001111100000000000100100		2		2			2		1	1	1	50	50	50	50	2		
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H5528	026	0	1	04	01	H5528_026_0	5	4	50% Cost Sharing up to $1000	10		000000000000000000000001	1	1000.00	2			2		2		1		50		50			
H5528	026	0	1	04	01	H5528_026_0	5	2	$0 Cost Sharing	01	0000010000000000000000000000001000000		2		1	0.00	0.00	2		2		2							
H5528	804	0	1	04	01	H5528_804_0	4	3	0% Coinsurance	01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
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H5529	008	1	1	04	01	H5529_008_1	12	10	Ambulance	01	0000000000000000000000001000000000000		2		1	175.00	175.00	2		2		2							
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H5529	008	1	1	04	01	H5529_008_1	12	3	Outpatient	01	0000000000000000000010000000000000000		2		1	25.00	50.00	2		2		1		30		30			
H5529	008	1	1	04	01	H5529_008_1	12	9	Labs	01	0000000000000000100000000000000000000		2		2			2		1	2	1		20		20	1	25.00	50.00
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H5529	008	2	1	04	01	H5529_008_2	13	9	Labs	01	0000000000000000100000000000000000000		2		2			2		1	2	1		20		20	1	35.00	50.00
H5529	008	2	1	04	01	H5529_008_2	13	8	Radiology	01	0000000000000001000100000000000000000		2		1	110.00	170.00	2		1	2	2					1	35.00	50.00
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H5529	009	1	1	04	01	H5529_009_1	12	4	PCP	01	0000001000001000000000000000000000000		2		1	25.00	25.00	2		2		2							
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H5529	009	1	1	04	01	H5529_009_1	12	9	Labs	01	0000000000000000101000000000000000000		2		2			2		1	2	1		20		20	1	25.00	40.00
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H5529	009	2	1	04	01	H5529_009_2	12	8	Radiology	01	0000000000000001000100000000000000000		2		1	110.00	170.00	2		1	2	2					1	25.00	40.00
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H5530	006	1	1	04	01	H5530_006_1	14	9	LABS	01	0000000000000000100000000000000000000		2		1	25.00	25.00	2		1	2	2					1	30.00	50.00
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H5530	006	1	1	04	01	H5530_006_1	14	3	Outpatient Hospital	01	0000000000000000000010000000000000000		2		1	30.00	50.00	2		2		1		30		30			
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H5530	006	1	1	04	01	H5530_006_1	14	7	50% for Web/Phone Based Technology	10		000000000000000010000000	2		2			2		2		1		50		50			
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H5530	006	2	1	04	01	H5530_006_2	14	3	Outpatient Hospital	01	0000000000000000000010000000000000000		2		1	30.00	50.00	2		2		1		30		30			
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H5530	006	2	1	04	01	H5530_006_2	14	7	50% for Web/Phone Based Technoloy	10		000000000000000010000000	2		2			2		2		1		50		50			
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H5530	806	0	1	04	01	H5530_806_0	6	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5530	806	0	1	04	01	H5530_806_0	6	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5530	808	0	2	04	01	H5530_808_0	6	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5530	808	0	2	04	01	H5530_808_0	6	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5532	001	0	1	04	01	H5532_001_0	2	10	Group 10	11	0000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H5532	001	0	1	04	01	H5532_001_0	2	11	Group 11	01	0000010000000000000000000100000010000		2		2			2		2		1		50		50			
H5532	001	0	1	04	01	H5532_001_0	2	12	Group 12	01	0000000000000000000000000000010000000		2		2			2		2		1		0		40			
H5532	001	0	1	04	01	H5532_001_0	2	13	Group 13	01	0000000000001000000000000000000000000		2		1	45.00	70.00	2		2		2							
H5532	001	0	1	04	01	H5532_001_0	2	1	Group 1	01	0000001000000000000000000000000000000		2		1	45.00	45.00	2		2		2							
H5532	001	0	1	04	01	H5532_001_0	2	3	Group 3	11	0000000000000000000011000011001100010	000000000000000100000000	2		2			2		2		1		40		40			
H5532	001	0	1	04	01	H5532_001_0	2	2	Group 2	11	0111000111010010000000000000000001101	000001000000000000001010	2		1	70.00	70.00	2		2		2							
H5532	001	0	1	04	01	H5532_001_0	2	4	Group 4	01	0000000000000001111100000000000000000		2		1	13.00	21.00	2		1	2	1		40		40	1	45.00	70.00
H5532	001	0	1	04	01	H5532_001_0	2	5	Group 5	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H5532	001	0	1	04	01	H5532_001_0	2	6	Group 6	01	0000100000000000000000000000000000000		2		1	75.00	75.00	2		2		2							
H5532	001	0	1	04	01	H5532_001_0	2	7	Group 7	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H5532	001	0	1	04	01	H5532_001_0	2	8	Group 8	01	0000000000100100000000100000000000000		2		1	35.00	45.00	2		2		2							
H5532	001	0	1	04	01	H5532_001_0	2	9	Group 9	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H5533	003	0	1	04	01	H5533_003_0	5	5	OON Routine Vision	10		000000000000000000001100	1	100.00	1	0.00	0.00	2		2		2							
H5533	003	0	1	04	01	H5533_003_0	5	2	30% Coins - PCP/Spec Copay could apply	01	0000000000000001111100000000000000000		2		2			2		1	2	1		30		30	1	40.00	60.00
H5533	003	0	1	04	01	H5533_003_0	5	3	$40 OON Copay	11	0000001100000000000000000000000000000	000010000000000000000000	2		1	40.00	40.00	2		2		2							
H5533	003	0	1	04	01	H5533_003_0	5	1	30% Coinsurance	11	0111110010000010000011011000111000010	000000100000000100000000	2		2			2		2		1		30		30			
H5533	003	0	1	04	01	H5533_003_0	5	7	50% coins - PCP/Spec Copay could apply	01	0000000000000000000000000000000100000		2		2			2		1	2	1		50		50	1	40.00	60.00
H5533	003	0	1	04	01	H5533_003_0	5	6	50% OON	11	0000000000000000000000000111000010000	000000000000000010100000	2		2			2		2		1		50		50			
H5533	003	0	1	04	01	H5533_003_0	5	4	$60 OON Copay	11	0000000001111100000000100000000001101	000001000000000000000000	2		1	60.00	60.00	2		2		2							
H5533	005	0	1	04	01	H5533_005_0	5	4	50% OON	11	0000000000000000000000000111000000000	000000000000000010100000	2		2			2		2		1		50		50			
H5533	005	0	1	04	01	H5533_005_0	5	5	30% coins PCP/Spec copay could apply	01	0000000000000001111100000000000100000		2		2			2		1	2	1		30		30	1	30.00	50.00
H5533	005	0	1	04	01	H5533_005_0	5	6	OON Routine Vision	10		000000000000000000001100	1	200.00	1	0.00	0.00	2		2		2							
H5533	005	0	1	04	01	H5533_005_0	5	7	OON Hearing Aids 50% coins w/max	10		000000000000000000000001	1	1500.00	2			2		2		1		50		50			
H5533	005	0	1	04	01	H5533_005_0	5	3	$50 OON Copay	11	0000000011111110000000100000000001101	000001000000000000000010	2		1	50.00	50.00	2		2		2							
H5533	005	0	1	04	01	H5533_005_0	5	2	$30 OON Copay	11	0000001100000000000000000000000000000	000010000000000000000000	2		1	30.00	30.00	2		2		2							
H5533	005	0	1	04	01	H5533_005_0	5	1	30% OON coinsurance	11	0111110000000000000011011000111010010	000000100000000100000000	2		2			2		2		1		30		30			
H5533	006	0	1	04	01	H5533_006_0	6	7	50% coins - PCP/Spec Copay could apply	01	0000000000000000000000000000000100000		2		2			2		1	2	1		50		50	1	40.00	60.00
H5533	006	0	1	04	01	H5533_006_0	6	6	50% OON	11	0000000000000000000000000111000010000	000000000000000010100000	2		2			2		2		1		50		50			
H5533	006	0	1	04	01	H5533_006_0	6	4	$60 OON Copay	11	0000000001111100000000100000000001101	000001000000000000000000	2		1	60.00	60.00	2		2		2							
H5533	006	0	1	04	01	H5533_006_0	6	3	$40 OON Copay	11	0000001100000000000000000000000000000	000010000000000000000000	2		1	40.00	40.00	2		2		2							
H5533	006	0	1	04	01	H5533_006_0	6	2	30% Coins - PCP/Spec Copay could apply	01	0000000000000001111100000000000000000		2		2			2		1	2	1		30		30	1	40.00	60.00
H5533	006	0	1	04	01	H5533_006_0	6	1	30% Coinsurance	11	0111110010000010000011011000111000010	000000100000000100000000	2		2			2		2		1		30		30			
H5533	006	0	1	04	01	H5533_006_0	6	5	OON Routine Vision	10		000000000000000000001100	1	100.00	1	0.00	0.00	2		2		2							
H5533	801	0	1	04	01	H5533_801_0	3	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5533	801	0	1	04	01	H5533_801_0	3	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5533	802	0	1	04	01	H5533_802_0	3	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5533	802	0	1	04	01	H5533_802_0	3	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5533	803	0	1	04	01	H5533_803_0	3	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5533	803	0	1	04	01	H5533_803_0	3	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5970	001	0	1	04	01	H5970_001_0	3	4		01	0000000000000000000000000000001000000		2		1	25.00	60.00	2		2		2							
H5970	001	0	1	04	01	H5970_001_0	3	3		11	0000001000000000000000000000000000000	000000000000000100000000	2		1	25.00	25.00	2		2		2							
H5970	001	0	1	04	01	H5970_001_0	3	9		01	0000000000000001110100000000000100000		2		1	25.00	60.00	2		2		1		20		20			
H5970	001	0	1	04	01	H5970_001_0	3	8		01	0000110000000000001011100111100010000		2		2			2		2		1		20		20			
H5970	001	0	1	04	01	H5970_001_0	3	7		01	0000000000000000000000000000010000000		2		1	0.00	60.00	2		2		1		0		20			
H5970	001	0	1	04	01	H5970_001_0	3	6		01	0000000101111100000000000000000001101		2		1	60.00	60.00	2		2		2							
H5970	001	0	1	04	01	H5970_001_0	3	5		01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H5970	001	0	1	04	01	H5970_001_0	3	1		11	0000000000000000000000010000000000010	000000100000000000000000	2		1	0.00	0.00	2		2		2							
H5970	001	0	1	04	01	H5970_001_0	3	10		01	0111000010000010000000000000000000000		2		1	60.00	60.00	2		2		1		20		20			
H5970	001	0	1	04	01	H5970_001_0	3	11		10		000000000010000010110000	2		2			2		2		1		50		50			
H5970	001	0	1	04	01	H5970_001_0	3	12		10		000000000100000000000000	1	50.00	2			2		2		1		50		50			
H5970	001	0	1	04	01	H5970_001_0	3	2		10		000000000000000000001000	1	40.00	1	0.00	0.00	2		2		2							
H5970	002	0	1	04	01	H5970_002_0	3	8		10		000000000000000000000010	2		2			2		2		1		25		25			
H5970	002	0	1	04	01	H5970_002_0	3	7		01	0000000000000000000010000000000000000		2		2			2		2		1		20		50			
H5970	002	0	1	04	01	H5970_002_0	3	6		01	0000010000000000000000000100000000000		2		2			2		2		1		20		20			
H5970	002	0	1	04	01	H5970_002_0	3	5		01	0000000000000000000000000000010000000		2		2			2		2		1		0		50			
H5970	002	0	1	04	01	H5970_002_0	3	4		01	0000000000000000000000000000100000000		2		2			2		2		1		0		20			
H5970	002	0	1	04	01	H5970_002_0	3	9		10		000000000000000000000001	1	1000.00	2			2		2		1		25		25			
H5970	002	0	1	04	01	H5970_002_0	3	2		10		000000000000000000001000	1	40.00	1	0.00	0.00	2		2		2							
H5970	002	0	1	04	01	H5970_002_0	3	11		10		000000000100000000000000	1	50.00	2			2		2		1		50		50			
H5970	002	0	1	04	01	H5970_002_0	3	10		11	0111101111111111111101100011001111101	000000000010000110110000	2		2			2		2		1		50		50			
H5970	002	0	1	04	01	H5970_002_0	3	1		11	0000000000000000000000010000000000010	000000100000000000000000	2		1	0.00	0.00	2		2		2							
H5970	002	0	1	04	01	H5970_002_0	3	3		01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H5970	004	0	1	04	01	H5970_004_0	3	4		01	0000000000000000000000000000001000000		2		2			2		2		1		0		0			
H5970	004	0	1	04	01	H5970_004_0	3	3		01	0000000000000000000000001000000000000		2		1	10.00	10.00	2		2		2							
H5970	004	0	1	04	01	H5970_004_0	3	2		10		000000000000000000001000	1	40.00	1	0.00	0.00	2		2		2							
H5970	004	0	1	04	01	H5970_004_0	3	12		01	0000000000000000000000000000010000000		2		1	0.00	0.00	2		2		1		50		50			
H5970	004	0	1	04	01	H5970_004_0	3	11		10		000000000100000000000000	1	50.00	2			2		2		1		50		50			
H5970	004	0	1	04	01	H5970_004_0	3	10		11	0111101111111111111101100011000111101	000000000010000110110000	2		2			2		2		1		50		50			
H5970	004	0	1	04	01	H5970_004_0	3	1		11	0000000000000000000000010000000000010	000000100000000000000000	2		1	0.00	0.00	2		2		2							
H5970	004	0	1	04	01	H5970_004_0	3	5		01	0000000000000000000000000100100000000		2		2			2		2		1		20		20			
H5970	004	0	1	04	01	H5970_004_0	3	9		01	0000010000000000000000000000000000000		2		2			2		2		1		35		35			
H5970	004	0	1	04	01	H5970_004_0	3	8		10		000000000000000000000001	1	1000.00	2			2		2		1		25		25			
H5970	004	0	1	04	01	H5970_004_0	3	7		10		000000000000000000000010	2		2			2		2		1		25		25			
H5970	004	0	1	04	01	H5970_004_0	3	6		01	0000000000000000000010000000000000000		2		2			2		2		1		20		50			
H5970	008	0	1	04	01	H5970_008_0	3	1		11	0000000000000000000000010000000000010	000000100000000000000000	2		1	0.00	0.00	2		2		2							
H5970	008	0	1	04	01	H5970_008_0	3	10		01	0000000000000001100100000000000100000		2		1	20.00	60.00	2		2		1		20		20			
H5970	008	0	1	04	01	H5970_008_0	3	9		01	0000110000000000011011100111000010000		2		2			2		2		1		20		20			
H5970	008	0	1	04	01	H5970_008_0	3	8		01	0000000000000000000000000000010000000		2		1	20.00	60.00	2		2		1		0		20			
H5970	008	0	1	04	01	H5970_008_0	3	7		01	0000000000000000000000000000100000000		2		2			2		2		1		0		20			
H5970	008	0	1	04	01	H5970_008_0	3	6		01	0000000101111100000000000000000001101		2		1	60.00	60.00	2		2		2							
H5970	008	0	1	04	01	H5970_008_0	3	5		01	0000000000000000000000001000000000000		2		1	275.00	275.00	2		2		2							
H5970	008	0	1	04	01	H5970_008_0	3	4		01	0000000000000000000000000000001000000		2		1	20.00	60.00	2		2		2							
H5970	008	0	1	04	01	H5970_008_0	3	3		11	0000001000000000000000000000000000000	000000000000000100000000	2		1	20.00	20.00	2		2		2							
H5970	008	0	1	04	01	H5970_008_0	3	2		10		000000000000000000001000	1	40.00	1	0.00	0.00	2		2		2							
H5970	008	0	1	04	01	H5970_008_0	3	13		10		000000000100000000000000	1	50.00	2			2		2		1		50		50			
H5970	008	0	1	04	01	H5970_008_0	3	12		10		000000000010000010000000	2		2			2		2		1		50		50			
H5970	008	0	1	04	01	H5970_008_0	3	11		01	0111000010000010000000000000000000000		2		1	60.00	60.00	2		2		1		20		20			
H5970	010	0	1	04	01	H5970_010_0	3	1		11	0000000000000000000000010000000000010	000000100000000000000000	2		1	0.00	0.00	2		2		2							
H5970	010	0	1	04	01	H5970_010_0	3	5		01	0000000101111100000000000000000001101		2		1	40.00	40.00	2		2		2							
H5970	010	0	1	04	01	H5970_010_0	3	6		01	0000110000000000001011100111100010000		2		2			2		2		1		20		20			
H5970	010	0	1	04	01	H5970_010_0	3	7		01	0000000000000000000000000000010000000		2		1	0.00	40.00	2		2		1		20		20			
H5970	010	0	1	04	01	H5970_010_0	3	8		01	0000000000000001110100000000000100000		2		1	20.00	40.00	2		2		1		20		20			
H5970	010	0	1	04	01	H5970_010_0	3	4		01	0000000000000000000000000000001000000		2		1	20.00	40.00	2		2		2							
H5970	010	0	1	04	01	H5970_010_0	3	9		01	0111000010000010000000000000000000000		2		1	40.00	40.00	2		2		1		20		20			
H5970	010	0	1	04	01	H5970_010_0	3	2		10		000000000000000000001000	1	40.00	1	0.00	0.00	2		2		2							
H5970	010	0	1	04	01	H5970_010_0	3	13		10		000000000100000000000000	1	50.00	2			2		2		1		50		50			
H5970	010	0	1	04	01	H5970_010_0	3	12		10		000000000010000010000000	2		2			2		2		1		50		50			
H5970	010	0	1	04	01	H5970_010_0	3	11		10		000000000000000000000001	1	1000.00	2			2		2		1		25		25			
H5970	010	0	1	04	01	H5970_010_0	3	10		10		000000000000000000000010	2		2			2		2		1		25		25			
H5970	010	0	1	04	01	H5970_010_0	3	3		11	0000001000000000000000001000000000000	000000000000000100000000	2		1	20.00	20.00	2		2		2							
H5970	013	0	1	04	01	H5970_013_0	5	4		01	0000000000000000000000000000010000000		2		1	0.00	0.00	2		2		1		20		20			
H5970	013	0	1	04	01	H5970_013_0	5	5		10		000000000000000010000000	2		2			2		2		1		50		50			
H5970	013	0	1	04	01	H5970_013_0	5	1		11	0000000000000000000000010000000000010	000000100000000000000000	2		1	0.00	0.00	2		2		2							
H5970	013	0	1	04	01	H5970_013_0	5	2		01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H5970	013	0	1	04	01	H5970_013_0	5	3		11	0111111111111111111111100111101111101	000000000000000100000000	2		2			2		2		1		20		20			
H5970	801	0	1	04	01	H5970_801_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5970	801	0	1	04	01	H5970_801_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5970	802	0	1	04	01	H5970_802_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5970	802	0	1	04	01	H5970_802_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5970	803	0	1	04	01	H5970_803_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5970	803	0	1	04	01	H5970_803_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5970	805	0	2	04	01	H5970_805_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5970	805	0	2	04	01	H5970_805_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5970	806	0	2	04	01	H5970_806_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5970	806	0	2	04	01	H5970_806_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5970	807	0	2	04	01	H5970_807_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5970	807	0	2	04	01	H5970_807_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H5970	814	0	1	04	01	H5970_814_0	3	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H5970	814	0	1	04	01	H5970_814_0	3	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H6328	001	0	1	04	01	H6328_001_0	10	3	$35 Copay	11	0000000001011000000000000000000001101	000000000000000000101010	2		1	35.00	35.00	2		2		2							
H6328	001	0	1	04	01	H6328_001_0	10	5	$50 Copay	01	0000000000100100000000100000100000000		2		1	50.00	50.00	2		2		2							
H6328	001	0	1	04	01	H6328_001_0	10	15	50% Coinsurance, $300 Max Ben Coverage	10		000000000000000000000001	1	300.00	2			2		2		1		50		50			
H6328	001	0	1	04	01	H6328_001_0	10	14	50% Coinsurance, $150 Max Ben Coverage	10		000000000000000000000100	1	150.00	2			2		2		1		50		50			
H6328	001	0	1	04	01	H6328_001_0	10	13	50% Coinsurance	01	0000000000000000000000000000000000010		2		2			2		2		1		50		50			
H6328	001	0	1	04	01	H6328_001_0	10	12	30% Coinsurance	01	0000000000000000001000010110000010000		2		2			2		2		1		30		30			
H6328	001	0	1	04	01	H6328_001_0	10	11	20% Coinsurance	01	0000000000000000000000000001001100000		2		2			2		2		1		20		20			
H6328	001	0	1	04	01	H6328_001_0	10	10	$75 to $200 Copay	01	0000000000000000010000000000000000000		2		1	75.00	200.00	2		2		2							
H6328	001	0	1	04	01	H6328_001_0	10	1	$20 Copay	01	0111000110000010000000000000000000000		2		1	20.00	20.00	2		2		2							
H6328	001	0	1	04	01	H6328_001_0	10	9	$10 to $25 Copay	01	0000000000000001100100000000000000000		2		1	10.00	25.00	2		2		2							
H6328	001	0	1	04	01	H6328_001_0	10	8	$200 Copay	01	0000000000000000000010000000000000000		2		1	200.00	200.00	2		2		2							
H6328	001	0	1	04	01	H6328_001_0	10	7	$150 Copay	01	0000000000000000000001000000000000000		2		1	150.00	150.00	2		2		2							
H6328	001	0	1	04	01	H6328_001_0	10	6	$100 Copay	01	0000100000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H6328	001	0	1	04	01	H6328_001_0	10	4	$40 Copay	01	0000010000000000000000000000000000000		2		1	40.00	40.00	2		2		2							
H6328	001	0	1	04	01	H6328_001_0	10	2	$30 Copay	11	0000001000000000000000000000010000000	000000010000000010000000	2		1	30.00	30.00	2		2		2							
H6328	002	0	1	04	01	H6328_002_0	9	8	$225 Copay	01	0000000000000000000010000000000000000		2		1	225.00	225.00	2		2		2							
H6328	002	0	1	04	01	H6328_002_0	9	7	$175 Copay	01	0000000000000000000001000000000000000		2		1	175.00	175.00	2		2		2							
H6328	002	0	1	04	01	H6328_002_0	9	6	$125 Copay	01	0000100000000000000000000000000000000		2		1	125.00	125.00	2		2		2							
H6328	002	0	1	04	01	H6328_002_0	9	5	$100 Copay	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H6328	002	0	1	04	01	H6328_002_0	9	4	$55 Copay	01	0000000000100100000000100000100000000		2		1	55.00	55.00	2		2		2							
H6328	002	0	1	04	01	H6328_002_0	9	3	$40 Copay	11	0000010001011000000000000000000001101	000000000000000000001000	2		1	40.00	40.00	2		2		2							
H6328	002	0	1	04	01	H6328_002_0	9	11	20% Coinsurance	01	0000000000000000000000000001001100000		2		2			2		2		1		20		20			
H6328	002	0	1	04	01	H6328_002_0	9	10	$75 to $200 Copay	01	0000000000000000010000000000000000000		2		1	75.00	200.00	2		2		2							
H6328	002	0	1	04	01	H6328_002_0	9	1	$20 Copay	01	0111000110000010000000000000000000000		2		1	20.00	20.00	2		2		2							
H6328	002	0	1	04	01	H6328_002_0	9	2	$30 Copay	11	0000001000000000000000000000010000000	000000010000000010000000	2		1	30.00	30.00	2		2		2							
H6328	002	0	1	04	01	H6328_002_0	9	14	50% Coinsurance, $100 Benefit Limit	10		000000000000000000000100	1	100.00	2			2		2		1		50		50			
H6328	002	0	1	04	01	H6328_002_0	9	9	$10 to $25 Copay	01	0000000000000001100100000000000000000		2		1	10.00	25.00	2		2		2							
H6328	002	0	1	04	01	H6328_002_0	9	12	30% Coinsurance	01	0000000000000000001000010110000010000		2		2			2		2		1		30		30			
H6328	002	0	1	04	01	H6328_002_0	9	13	50% Coinsurance	01	0000000000000000000000000000000000010		2		2			2		2		1		50		50			
H6328	003	0	1	04	01	H6328_003_0	9	3	$30 copay	11	0000000000000000000000000000010000000	000000010000000010000000	2		1	30.00	30.00	2		2		2							
H6328	003	0	1	04	01	H6328_003_0	9	4	$40 copay	01	0000001000000000000000000000000000000		2		1	40.00	40.00	2		2		2							
H6328	003	0	1	04	01	H6328_003_0	9	5	$45 Copay	01	0000010000000000000000000000000000000		2		1	45.00	45.00	2		2		2							
H6328	003	0	1	04	01	H6328_003_0	9	6	$50 Copay	01	0000000001011000000000000000000001101		2		1	50.00	50.00	2		2		2							
H6328	003	0	1	04	01	H6328_003_0	9	7	$60 Copay	01	0000000000100100000000100000100000000		2		1	60.00	60.00	2		2		2							
H6328	003	0	1	04	01	H6328_003_0	9	8	$150 Copay	01	0000100000000000000000000000000000000		2		1	150.00	150.00	2		2		2							
H6328	003	0	1	04	01	H6328_003_0	9	9	$200 Copay	01	0000000000000000000001001000000000000		2		1	200.00	200.00	2		2		2							
H6328	003	0	1	04	01	H6328_003_0	9	1	$20 copay	01	0000000100000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H6328	003	0	1	04	01	H6328_003_0	9	10	$250 Copay	01	0000000000000000000010000000000000000		2		1	250.00	250.00	2		2		2							
H6328	003	0	1	04	01	H6328_003_0	9	11	$10 to $25 Copay	01	0000000000000001100100000000000000000		2		1	10.00	25.00	2		2		2							
H6328	003	0	1	04	01	H6328_003_0	9	12	$75 to $250 Copay	01	0000000000000000010000000000000000000		2		1	75.00	250.00	2		2		2							
H6328	003	0	1	04	01	H6328_003_0	9	13	20% Coinsurance	01	0000000000000000000000000001001100000		2		2			2		2		1		20		20			
H6328	003	0	1	04	01	H6328_003_0	9	14	30% Coinsurance	01	0000000000000000001000010110000010000		2		2			2		2		1		30		30			
H6328	003	0	1	04	01	H6328_003_0	9	15	50% Coinsurance	01	0000000000000000000000000000000000010		2		2			2		2		1		50		50			
H6328	003	0	1	04	01	H6328_003_0	9	2	$25 copay	01	0111000010000010000000000000000000000		2		1	25.00	25.00	2		2		2							
H6328	005	0	1	04	01	H6328_005_0	7	1	$20 Copay	01	0111000110000010000000000000000000000		2		1	20.00	20.00	2		2		2							
H6328	005	0	1	04	01	H6328_005_0	7	10	$75 to $200 Copay	01	0000000000000000010000000000000000000		2		1	75.00	200.00	2		2		2							
H6328	005	0	1	04	01	H6328_005_0	7	9	$10 to $25 Copay	01	0000000000000001100100000000000000000		2		1	10.00	25.00	2		2		2							
H6328	005	0	1	04	01	H6328_005_0	7	8	$200 Copay	01	0000000000000000000010000000000000000		2		1	200.00	200.00	2		2		2							
H6328	005	0	1	04	01	H6328_005_0	7	7	$150 Copay	01	0000000000000000000001000000000000000		2		1	150.00	150.00	2		2		2							
H6328	005	0	1	04	01	H6328_005_0	7	6	$100 Copay	01	0000100000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H6328	005	0	1	04	01	H6328_005_0	7	5	$50 Copay	01	0000000000100100000000100000100000000		2		1	50.00	50.00	2		2		2							
H6328	005	0	1	04	01	H6328_005_0	7	4	$40 Copay	01	0000010000000000000000000000000000000		2		1	40.00	40.00	2		2		2							
H6328	005	0	1	04	01	H6328_005_0	7	3	$35 Copay	11	0000000001011000000000000000000001101	000000000000000000101010	2		1	35.00	35.00	2		2		2							
H6328	005	0	1	04	01	H6328_005_0	7	11	20% Coinsurance	01	0000000000000000000000000001001100000		2		2			2		2		1		20		20			
H6328	005	0	1	04	01	H6328_005_0	7	12	30% Coinsurance	01	0000000000000000001000010110000010000		2		2			2		2		1		30		30			
H6328	005	0	1	04	01	H6328_005_0	7	13	50% Coinsurance	01	0000000000000000000000000000000000010		2		2			2		2		1		50		50			
H6328	005	0	1	04	01	H6328_005_0	7	14	50% Coinsurance, $150 Max Ben Coverage	10		000000000000000000000100	1	150.00	2			2		2		1		50		50			
H6328	005	0	1	04	01	H6328_005_0	7	15	50% Coinsurance, $300 Max Ben Coverage	10		000000000000000000000001	1	300.00	2			2		2		1		50		50			
H6328	005	0	1	04	01	H6328_005_0	7	2	$30 Copay	11	0000001000000000000000000000010000000	000000010000000010000000	2		1	30.00	30.00	2		2		2							
H6328	801	0	1	04	01	H6328_801_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H6328	801	0	1	04	01	H6328_801_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H6328	802	0	1	04	01	H6328_802_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H6328	802	0	1	04	01	H6328_802_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H6328	803	0	1	04	01	H6328_803_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H6328	803	0	1	04	01	H6328_803_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H6328	804	0	1	04	01	H6328_804_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H6328	804	0	1	04	01	H6328_804_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H6528	006	0	1	04	01	H6528_006_0	4	8	Group 8	01	0000000000000000000011000011100010000		2		2			2		2		1		20		20			
H6528	006	0	1	04	01	H6528_006_0	4	9	Group 9	11	0000000100000000000000000000000000000	000000000000000000100000	2		1	20.00	20.00	2		2		2							
H6528	006	0	1	04	01	H6528_006_0	4	2	Group 2	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
H6528	006	0	1	04	01	H6528_006_0	4	15	Group 15	01	0000000000000000000000000100000000000		2		2			2		2		1		40		40			
H6528	006	0	1	04	01	H6528_006_0	4	14	Group 14	01	0000000000000001111100000000000000000		2		1	13.00	15.00	2		1	2	1		20		20	1	30.00	50.00
H6528	006	0	1	04	01	H6528_006_0	4	13	Group 13	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H6528	006	0	1	04	01	H6528_006_0	4	12	Group 12	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H6528	006	0	1	04	01	H6528_006_0	4	11	Group 11	11	0000000000000000000000010000011100010	000000100000000110010000	2		1	0.00	0.00	2		2		2							
H6528	006	0	1	04	01	H6528_006_0	4	10	Group 10	10		000000000000000000001000	2		1	25.00	25.00	2		2		2							
H6528	006	0	1	04	01	H6528_006_0	4	1	Group 1	11	0111000001011000000000000000000001001	000001000000000000000000	2		1	50.00	50.00	2		2		2							
H6528	006	0	1	04	01	H6528_006_0	4	6	Group 6	01	0000000010100110000000100000000000000		2		1	30.00	40.00	2		2		2							
H6528	006	0	1	04	01	H6528_006_0	4	5	Group 5	01	0000000000000000000000000000000000100		2		1	0.00	50.00	2		2		2							
H6528	006	0	1	04	01	H6528_006_0	4	4	Group 4	11	0000001000000000000000000000000000000	000000000000000000000010	2		1	30.00	30.00	2		2		2							
H6528	006	0	1	04	01	H6528_006_0	4	3	Group 3	01	0000010000000000000000000000000000000		2		2			2		2		1		50		50			
H6528	006	0	1	04	01	H6528_006_0	4	7	Group 7	10		000000000000000000000100	1	100.00	1	0.00	0.00	2		2		2							
H6528	016	0	1	04	01	H6528_016_0	4	8	Group 8	01	0000000000000000000011000011100010000		2		2			2		2		1		20		20			
H6528	016	0	1	04	01	H6528_016_0	4	9	Group 9	01	0000000000000001111100000000000000000		2		1	13.00	15.00	2		1	2	1		20		20	1	25.00	50.00
H6528	016	0	1	04	01	H6528_016_0	4	12	Group 12	01	0000000000000000000000000000000000100		2		1	0.00	50.00	2		2		2							
H6528	016	0	1	04	01	H6528_016_0	4	11	Group 11	11	0000000000010000000000010000011100010	000001110000000010010000	2		1	0.00	0.00	2		2		2							
H6528	016	0	1	04	01	H6528_016_0	4	10	Group 10	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H6528	016	0	1	04	01	H6528_016_0	4	1	Group 1	01	0111000001000000000000000000000001001		2		1	50.00	50.00	2		2		2							
H6528	016	0	1	04	01	H6528_016_0	4	6	Group 6	01	0000000000100100000000100000000000000		2		1	30.00	40.00	2		2		2							
H6528	016	0	1	04	01	H6528_016_0	4	5	Group 5	11	0000000100000000000000000000000000000	000000000000000000100000	2		1	20.00	20.00	2		2		2							
H6528	016	0	1	04	01	H6528_016_0	4	4	Group 4	10		000000000000000000000100	1	100.00	1	0.00	0.00	2		2		2							
H6528	016	0	1	04	01	H6528_016_0	4	3	Group 3	01	0000010000000000000000000100000000000		2		2			2		2		1		50		50			
H6528	016	0	1	04	01	H6528_016_0	4	2	Group 2	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
H6528	016	0	1	04	01	H6528_016_0	4	15	Group 15	01	0000000010000010000000000000000000000		2		1	40.00	40.00	2		2		2							
H6528	016	0	1	04	01	H6528_016_0	4	7	Group 7	11	0000001000000000000000000000000000000	000000000000000000001010	2		1	25.00	25.00	2		2		2							
H6528	016	0	1	04	01	H6528_016_0	4	13	Group 13	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H6528	016	0	1	04	01	H6528_016_0	4	14	Group 14	01	0000000000001000000000000000000000000		2		1	25.00	50.00	2		2		2							
H6528	029	0	1	04	01	H6528_029_0	4	9	Group 9	01	0000000000000001111100000000000000000		2		1	13.00	15.00	2		1	2	1		20		20	1	20.00	50.00
H6528	029	0	1	04	01	H6528_029_0	4	8	Group 8	01	0000000000000000000011000011100010000		2		2			2		2		1		20		20			
H6528	029	0	1	04	01	H6528_029_0	4	7	Group 7	10		000000000000000000001000	2		1	25.00	25.00	2		2		2							
H6528	029	0	1	04	01	H6528_029_0	4	6	Group 6	01	0000000000100100000000100000000000000		2		1	30.00	40.00	2		2		2							
H6528	029	0	1	04	01	H6528_029_0	4	5	Group 5	01	0000000000000000000000000000000000100		2		1	0.00	50.00	2		2		2							
H6528	029	0	1	04	01	H6528_029_0	4	4	Group 4	11	0000001100000000000000000000000000000	000000000000000000100010	2		1	20.00	20.00	2		2		2							
H6528	029	0	1	04	01	H6528_029_0	4	3	Group 3	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
H6528	029	0	1	04	01	H6528_029_0	4	2	Group 2	01	0000010000000000000000000100000000000		2		2			2		2		1		50		50			
H6528	029	0	1	04	01	H6528_029_0	4	14	Group 14	01	0000000000001000000000000000000000000		2		1	20.00	50.00	2		2		2							
H6528	029	0	1	04	01	H6528_029_0	4	15	Group 15	01	0000000010000010000000000000000000000		2		1	40.00	40.00	2		2		2							
H6528	029	0	1	04	01	H6528_029_0	4	13	Group 13	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H6528	029	0	1	04	01	H6528_029_0	4	12	Group 12	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H6528	029	0	1	04	01	H6528_029_0	4	11	Group 11	11	0000000000010000000000010000011100010	000001110000000010010000	2		1	0.00	0.00	2		2		2							
H6528	029	0	1	04	01	H6528_029_0	4	10	Group 10	10		000000000000000000000100	1	100.00	1	0.00	0.00	2		2		2							
H6528	029	0	1	04	01	H6528_029_0	4	1	Group 1	01	0111000001000000000000000000000001001		2		1	50.00	50.00	2		2		2							
H6528	030	0	1	04	01	H6528_030_0	4	2	Group 2	01	0000010000000000000000000000000000000		2		2			2		2		1		50		50			
H6528	030	0	1	04	01	H6528_030_0	4	6	Group 6	01	0000000010100110000000100000000000000		2		1	30.00	40.00	2		2		2							
H6528	030	0	1	04	01	H6528_030_0	4	14	Group 14	01	0000000000001000000000000000000000000		2		1	25.00	50.00	2		2		2							
H6528	030	0	1	04	01	H6528_030_0	4	13	Group 13	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H6528	030	0	1	04	01	H6528_030_0	4	12	Group 12	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
H6528	030	0	1	04	01	H6528_030_0	4	11	Group 11	11	0000000000000000000000010000011100010	000000100000000110010000	2		1	0.00	0.00	2		2		2							
H6528	030	0	1	04	01	H6528_030_0	4	10	Group 10	10		000000000000000000000100	1	100.00	1	0.00	0.00	2		2		2							
H6528	030	0	1	04	01	H6528_030_0	4	1	Group 1	11	0111000001010000000000000000000001001	000001000000000000000000	2		1	50.00	50.00	2		2		2							
H6528	030	0	1	04	01	H6528_030_0	4	3	Group 3	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
H6528	030	0	1	04	01	H6528_030_0	4	4	Group 4	11	0000001000000000000000000000000000000	000000000000000000001010	2		1	25.00	25.00	2		2		2							
H6528	030	0	1	04	01	H6528_030_0	4	5	Group 5	01	0000000000000000000000000000000000100		2		1	0.00	50.00	2		2		2							
H6528	030	0	1	04	01	H6528_030_0	4	9	Group 9	01	0000000000000001111100000000000000000		2		1	13.00	15.00	2		1	2	1		20		20	1	25.00	50.00
H6528	030	0	1	04	01	H6528_030_0	4	8	Group 8	01	0000000000000000000011000011100010000		2		2			2		2		1		20		20			
H6528	030	0	1	04	01	H6528_030_0	4	7	Group 7	11	0000000100000000000000000000000000000	000000000000000000100000	2		1	20.00	20.00	2		2		2							
H6528	030	0	1	04	01	H6528_030_0	4	15	Group 15	01	0000000000000000000000000100000000000		2		2			2		2		1		40		40			
H6609	001	0	1	04	01	H6609_001_0	4	7		10		000000000010000010100000	2		2			2		2		1		50		50			
H6609	001	0	1	04	01	H6609_001_0	4	8		10		000000000100000000000000	1	25.00	2			2		2		1		50		50			
H6609	001	0	1	04	01	H6609_001_0	4	6		11	0111111111111111111101100111001111111	000000000000000100000000	2		2			2		2		1		30		30			
H6609	001	0	1	04	01	H6609_001_0	4	1		11	0000000000000000000000010000000000000	000000100000000000000000	2		1	0.00	0.00	2		2		2							
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H6743	004	0	1	04	01	H6743_004_0	6	12	Preventive Dental	10		000000000000000000100000	1	500.00	1	15.00	15.00	2		2		2							
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H6743	005	0	1	04	01	H6743_005_0	6	11	Supplemental Eyewear - Every Year	10		000000000000000000000100	1	200.00	2			2		2		2							
H6743	005	0	1	04	01	H6743_005_0	6	12	Supplemental Podiatry	10		000001000000000000000000	1	500.00	1	25.00	25.00	2		2		2							
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H6743	005	0	1	04	01	H6743_005_0	6	6	Medicare Covered Chiropractic Services	01	0000000100000000000000000000000000000		2		1	15.00	15.00	2		2		2							
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H6743	005	0	1	04	01	H6743_005_0	6	10	Health Club Membership	10		000000000000000010000000	1	500.00	2			2		2		2							
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H6743	006	0	1	04	01	H6743_006_0	3	4	Chiropractic Services	01	0000000100000000000000000000000000000		2		2			2		2		1		50		50			
H6743	006	0	1	04	01	H6743_006_0	3	9	Laboratory Services	01	0000000000000000100000000000000000000		2		2			2		2		1		25		25			
H6743	006	0	1	04	01	H6743_006_0	3	6	Diagnostic Tests	01	0000000000000001000000000000000000000		2		2			2		2		1		30		30			
H6743	006	0	1	04	01	H6743_006_0	3	7	Preventive Services	11	0000000000000000000000010001011100010	000000100000000000000000	2		2			2		2		2							
H6743	006	0	1	04	01	H6743_006_0	3	8	Select the benefits that apply to the OO	01	0000010000000000000000000000000000000		2		2			2		2		1		15		15			
H6743	006	0	1	04	01	H6743_006_0	3	5	Ambulance	01	0000000000000000000000001000000000000		2		2			2		2		1		20		20			
H6743	007	0	1	04	01	H6743_007_0	5	10	Outpatient Hospital Services	01	0000000000000000000010000000000000000		2		2			2		2		1		40		40			
H6743	007	0	1	04	01	H6743_007_0	5	2	Specialist Services	01	0000000001000000000000000000000001101		2		1	50.00	50.00	2		2		2							
H6743	007	0	1	04	01	H6743_007_0	5	3	Outpatient Services	01	0111100010111110011101100110100010000		2		2			2		2		1		30		30			
H6743	007	0	1	04	01	H6743_007_0	5	4	Chiropractic Services	01	0000000100000000000000000000000000000		2		2			2		2		1		50		50			
H6743	007	0	1	04	01	H6743_007_0	5	5	Ambulance	01	0000000000000000000000001000000000000		2		2			2		2		1		20		20			
H6743	007	0	1	04	01	H6743_007_0	5	6	Diagnostic Tests	01	0000000000000001000000000000000000000		2		2			2		2		1		30		30			
H6743	007	0	1	04	01	H6743_007_0	5	7	Preventive Services	11	0000000000000000000000010001011100010	000000100000000000000000	2		2			2		2		2							
H6743	007	0	1	04	01	H6743_007_0	5	8	Select the benefits that apply to the HH	01	0000010000000000000000000000000000000		2		2			2		2		1		15		15			
H6743	007	0	1	04	01	H6743_007_0	5	9	Laboratory Services	01	0000000000000000100000000000000000000		2		2			2		2		1		25		25			
H6743	007	0	1	04	01	H6743_007_0	5	1	Primary Care Physician Services	01	0000001000000000000000000000000000000		2		1	40.00	40.00	2		2		2							
H6743	013	0	1	04	01	H6743_013_0	4	1	Primary Care Physician Services	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H6743	013	0	1	04	01	H6743_013_0	4	10	Comprehensive Dental, Eye &Hearing Exams	01	0000000000000000000000000000000001101		2		1	50.00	50.00	2		2		2							
H6743	013	0	1	04	01	H6743_013_0	4	9	Laboratory Services	01	0000000000000000100000000000000000000		2		2			2		2		1		25		25			
H6743	013	0	1	04	01	H6743_013_0	4	8	Select the benefits that apply to the OO	01	0000010000000000000000000000000000000		2		2			2		2		1		15		15			
H6743	013	0	1	04	01	H6743_013_0	4	7	Preventive Services	11	0000000000000000000000010001011100010	000000100000000000000000	2		2			2		2		2							
H6743	013	0	1	04	01	H6743_013_0	4	6	Diagnostic Tests	01	0000000000000001000000000000000000000		2		2			2		2		1		30		30			
H6743	013	0	1	04	01	H6743_013_0	4	5	Ambulance	01	0000000000000000000000001000000000000		2		2			2		2		1		20		20			
H6743	013	0	1	04	01	H6743_013_0	4	4	Chiropractic Services	01	0000000100000000000000000000000000000		2		2			2		2		1		50		50			
H6743	013	0	1	04	01	H6743_013_0	4	3	Outpatient Services	01	0111100010111110011111100110100010000		2		2			2		2		1		30		30			
H6743	013	0	1	04	01	H6743_013_0	4	2	Specialist Services	01	0000000001000000000000000000000000000		2		1	40.00	40.00	2		2		2							
H6743	014	0	1	04	01	H6743_014_0	7	8	Home Health	01	0000010000000000000000000000000000000		2		2			2		2		1		15		15			
H6743	014	0	1	04	01	H6743_014_0	7	7	Preventive Services	11	0000000000000000000000010001011100010	000000100000000000000000	2		2			2		2		2							
H6743	014	0	1	04	01	H6743_014_0	7	6	Diagnostic Tests	01	0000000000000001000000000000000000000		2		2			2		2		1		30		30			
H6743	014	0	1	04	01	H6743_014_0	7	5	Ambulance	01	0000000000000000000000001000000000000		2		2			2		2		1		20		20			
H6743	014	0	1	04	01	H6743_014_0	7	9	Laboratory Services	01	0000000000000000100000000000000000000		2		2			2		2		1		25		25			
H6743	014	0	1	04	01	H6743_014_0	7	3	Outpatient Services	01	0111100010111110011111100110100010000		2		2			2		2		1		30		30			
H6743	014	0	1	04	01	H6743_014_0	7	2	Specialist Services	01	0000000001000000000000000000000001101		2		1	50.00	50.00	2		2		2							
H6743	014	0	1	04	01	H6743_014_0	7	1	Primary Care Physician Services	01	0000001000000000000000000000000000000		2		1	40.00	40.00	2		2		2							
H6743	014	0	1	04	01	H6743_014_0	7	4	Chiropractic Services	01	0000000100000000000000000000000000000		2		2			2		2		1		50		50			
H6743	015	0	1	04	01	H6743_015_0	4	1	Preventive Services	11	0000000000000000100000010001011100010	000000100000000000000000	2		2			2		2		2							
H6743	015	0	1	04	01	H6743_015_0	4	10	Health Club Membership	10		000000000000000010000000	1	500.00	2			2		2		2							
H6743	015	0	1	04	01	H6743_015_0	4	2	Primary Care Services	01	0000001000000000000000000000000000000		2		1	30.00	30.00	2		2		2							
H6743	015	0	1	04	01	H6743_015_0	4	3	Specialist Services	11	0111100011111110000000100000000001101	000000000000000000001000	2		1	40.00	40.00	2		2		2							
H6743	015	0	1	04	01	H6743_015_0	4	4	Outpatient Hosptial Services	01	0000000000000000000010000000000000000		2		1	325.00	325.00	2		2		2							
H6743	015	0	1	04	01	H6743_015_0	4	5	Ambulance	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H6743	015	0	1	04	01	H6743_015_0	4	6	Chiropractic Services	01	0000000100000000000000000000000000000		2		2			2		2		1		50		50			
H6743	015	0	1	04	01	H6743_015_0	4	7	Radiology, ASC, DME, ESRD and Part B Rx	01	0000000000000000011101000110100010000		2		2			2		2		1		30		30			
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H6743	015	0	1	04	01	H6743_015_0	4	9	Diagnotic Tests	01	0000000000000001000000000000000000000		2		2			2		2		1		30		30			
H6743	016	0	1	04	01	H6743_016_0	6	8	Home Health Services	01	0000010000000000000000000000000000000		2		2			2		2		1		15		15			
H6743	016	0	1	04	01	H6743_016_0	6	7	Radiology, ASC, DME, ESRD and Part B Rx	01	0000000000000000011101000110100010000		2		2			2		2		1		30		30			
H6743	016	0	1	04	01	H6743_016_0	6	9	Diagnotic Tests	01	0000000000000001000000000000000000000		2		2			2		2		1		30		30			
H6743	016	0	1	04	01	H6743_016_0	6	6	Chiropractic Services	01	0000000100000000000000000000000000000		2		2			2		2		1		50		50			
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H6743	016	0	1	04	01	H6743_016_0	6	4	Outpatient Hosptial Services	01	0000000000000000000010000000000000000		2		1	325.00	325.00	2		2		2							
H6743	016	0	1	04	01	H6743_016_0	6	3	Specialist Services	11	0111100011111110000000100000000001101	000000000000000000001000	2		1	40.00	40.00	2		2		2							
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H6743	016	0	1	04	01	H6743_016_0	6	10	Health Club Membership	10		000000000000000010000000	1	500.00	2			2		2		2							
H6743	016	0	1	04	01	H6743_016_0	6	1	Preventive Services	11	0000000000000000100000010001011100010	000000100000000000000000	2		2			2		2		2							
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H6743	017	0	1	04	01	H6743_017_0	6	1	Primary Care Services	01	0000001000000000000000000000000000000		2		1	25.00	25.00	2		2		2							
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H6743	017	0	1	04	01	H6743_017_0	6	8	Home Health Services	01	0000010000000000000000000000000000000		2		2			2		2		1		15		15			
H6743	017	0	1	04	01	H6743_017_0	6	9	Diagnostic Tests	01	0000000000000001000000000000000000000		2		2			2		2		1		20		20			
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H6743	017	0	1	04	01	H6743_017_0	6	10	Health Club Membership	10		000000000000000010000000	1	500.00	2			2		2		2							
H6743	017	0	1	04	01	H6743_017_0	6	11	Supplemental Eyewear - Every 2 Years	10		000000000000000000000100	1	150.00	2			2		2		2							
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H6786	002	0	1	04	01	H6786_002_0	15	11	17A Eye Exams	10		000000000000000000001000	1	69.00	1	0.00	0.00	2		2		2							
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H6951	001	0	1	04	01	H6951_001_0	4	1	Eye Exams	11	0111111111111111111111110111111111111	000000000000000000001000	2		2			2		2		1		30		30			
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H6951	002	0	1	04	01	H6951_002_0	6	2	Ambulance Services	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H6951	002	0	1	04	01	H6951_002_0	6	1	Eye Exams	11	0111111111111111111111110111111111111	000000000000000000001000	2		2			2		2		1		30		30			
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H6951	003	0	1	04	01	H6951_003_0	6	1	Eye Exams	11	0111111111111111111111110111111111111	000000000000000000001000	2		2			2		2		1		20		20			
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H7006	001	0	1	04	01	H7006_001_0	6	9	Supplemental Eyewear	10		000000000000000000000100	1	150.00	2			2		2		2							
H7006	001	0	1	04	01	H7006_001_0	6	8	Preventive Dental	10		000000000000000000100000	1	500.00	2			2		2		2							
H7006	001	0	1	04	01	H7006_001_0	6	7	Health Club Membership	10		000000000000000010000000	1	500.00	2			2		2		2							
H7006	001	0	1	04	01	H7006_001_0	6	6	Diagnostic Radiology	01	0000000000000000010000000000000000000		2		2			2		2		1		20		20			
H7006	001	0	1	04	01	H7006_001_0	6	5	DME, Part B Drugs	01	0000000000000000000000000110000010000		2		2			2		2		1		20		20			
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H7006	003	0	1	04	01	H7006_003_0	7	7	Part B Drugs and Outpatient X-Rays, ESRD	01	0000010000000000000100000000100010000		2		2			2		2		1		20		20			
H7006	003	0	1	04	01	H7006_003_0	7	6	Radiology	01	0000000000000000011000000000000000000		2		2			2		2		1		30		30			
H7006	003	0	1	04	01	H7006_003_0	7	5	DME	01	0000000000000000000000000110000000000		2		2			2		2		1		30		30			
H7006	003	0	1	04	01	H7006_003_0	7	4	Ambulance	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
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H7006	003	0	1	04	01	H7006_003_0	7	2	Office Visits	11	0111101111111110000000100000000001101	000000000000000000001000	2		1	35.00	35.00	2		2		2							
H7006	003	0	1	04	01	H7006_003_0	7	10	Supplemental Eyewear	10		000000000000000000000100	1	100.00	2			2		2		2							
H7006	003	0	1	04	01	H7006_003_0	7	9	Preventive Dental	10		000000000000000000100000	1	500.00	1	35.00	35.00	2		2		2							
H7006	003	0	1	04	01	H7006_003_0	7	1	Preventive Services	11	0000000000000001100000010001011100010	000000100000000000000000	2		2			2		2		2							
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H7006	004	0	1	04	01	H7006_004_0	4	3	Outpatient Services, ASC	01	0000000000000000000011000000000000000		2		1	225.00	225.00	2		2		2							
H7006	004	0	1	04	01	H7006_004_0	4	2	Office Visits	11	0111101111111110000000100000000001101	000000000000000000001000	2		1	35.00	35.00	2		2		2							
H7006	004	0	1	04	01	H7006_004_0	4	10	Supplemental Eyewear	10		000000000000000000000100	1	100.00	2			2		2		2							
H7006	004	0	1	04	01	H7006_004_0	4	1	Preventive Services	11	0000000000000001100000010001011100010	000000100000000000000000	2		2			2		2		2							
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H7006	004	0	1	04	01	H7006_004_0	4	9	Preventive Dental	10		000000000000000000100000	1	500.00	1	35.00	35.00	2		2		2							
H7006	004	0	1	04	01	H7006_004_0	4	8	Health Club Membership	10		000000000000000010000000	1	500.00	2			2		2		2							
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H7006	004	0	1	04	01	H7006_004_0	4	6	Radiology	01	0000000000000000011000000000000000000		2		2			2		2		1		30		30			
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H7006	005	0	1	04	01	H7006_005_0	6	10	Outpatient Hosptial Services	01	0000000000000000000010000000000000000		2		2			2		2		1		40		40			
H7006	005	0	1	04	01	H7006_005_0	6	9	Laboratory Services	01	0000000000000000100000000000000000000		2		2			2		2		1		25		25			
H7006	005	0	1	04	01	H7006_005_0	6	8	Home Health	01	0000010000000000000000000000000000000		2		2			2		2		1		15		15			
H7006	005	0	1	04	01	H7006_005_0	6	7	Preventive Services	11	0000000000000000000000010001011100010	000000100000000000000000	2		2			2		2		2							
H7006	005	0	1	04	01	H7006_005_0	6	6	Diagnostic Tests	01	0000000000000001000000000000000000000		2		2			2		2		1		30		30			
H7006	005	0	1	04	01	H7006_005_0	6	5	Ambulance	01	0000000000000000000000001000000000000		2		2			2		2		1		20		20			
H7006	005	0	1	04	01	H7006_005_0	6	4	Chiropractic Services	01	0000000100000000000000000000000000000		2		2			2		2		1		50		50			
H7006	005	0	1	04	01	H7006_005_0	6	3	Outpatient Services	01	0111100010111110011101100110100010000		2		2			2		2		1		30		30			
H7006	005	0	1	04	01	H7006_005_0	6	2	Specialist Services	01	0000000001000000000000000000000001101		2		1	50.00	50.00	2		2		2							
H7006	005	0	1	04	01	H7006_005_0	6	11	Health Club Membership and Health Living	10		000000000000000010000000	1	250.00	2			2		2		2							
H7006	006	0	1	04	01	H7006_006_0	4	5	Ambulance	01	0000000000000000000000001000000000000		2		2			2		2		1		20		20			
H7006	006	0	1	04	01	H7006_006_0	4	6	Diagnostic Tests	01	0000000000000001000000000000000000000		2		2			2		2		1		30		30			
H7006	006	0	1	04	01	H7006_006_0	4	7	Preventive Services	11	0000000000000000000000010001011100010	000000100000000010000000	2		2			2		2		2							
H7006	006	0	1	04	01	H7006_006_0	4	8	Home Health	01	0000010000000000000000000000000000000		2		2			2		2		1		15		15			
H7006	006	0	1	04	01	H7006_006_0	4	9	Laboratory Services	01	0000000000000000100000000000000000000		2		2			2		2		1		25		25			
H7006	006	0	1	04	01	H7006_006_0	4	3	Outpatient Services	01	0111100010111110011101100110100010000		2		2			2		2		1		30		30			
H7006	006	0	1	04	01	H7006_006_0	4	2	Specialist Services	01	0000000001000000000000000000000001101		2		1	50.00	50.00	2		2		2							
H7006	006	0	1	04	01	H7006_006_0	4	10	Outpatient Hosptial Services	01	0000000000000000000010000000000000000		2		2			2		2		1		30		30			
H7006	006	0	1	04	01	H7006_006_0	4	1	Primary Care Physician Services	01	0000001000000000000000000000000000000		2		1	40.00	40.00	2		2		2							
H7006	006	0	1	04	01	H7006_006_0	4	4	Chiropractic Services	01	0000000100000000000000000000000000000		2		2			2		2		1		50		50			
H7301	002	0	1	04	01	H7301_002_0	7	2	Out of Network Copay Group 1	01	0000000000000000000000001000000000000		2		1	300.00	300.00	2		2		2							
H7301	002	0	1	04	01	H7301_002_0	7	1	Out of Network Coinsuance Group 1	11	0111111111111111111111110111111111011	000001100000000000000010	2		2			2		2		1		40		40			
H7301	002	0	1	04	01	H7301_002_0	7	6	Eye Exams	11	0000000000000000000000000000000000100	000000000000000000001000	2		2			2		1	1	1	40	40	40	40	2		
H7301	002	0	1	04	01	H7301_002_0	7	5	Out of Network-Fitness Non-Gym	10		000000000000000010000000	2		2			2		2		2							
H7301	002	0	1	04	01	H7301_002_0	7	4	Out of Network Fitness-Gym	10		000000000000000010000000	2		1	50.00	50.00	2		2		2							
H7301	002	0	1	04	01	H7301_002_0	7	3	Out of Network Coinsurance 2	10		000000000000000000100000	1	500.00	2			2		2		1		50		50			
H7301	006	0	1	04	01	H7301_006_0	5	2	Out of Network Copay Group 1	01	0000000000000000000000001000000000000		2		1	300.00	300.00	2		2		2							
H7301	006	0	1	04	01	H7301_006_0	5	1	Out of Network Coinsuance Group 1	11	0111111111111111000011110111111111111	000000100000000000001010	2		2			2		2		1		50		50			
H7301	006	0	1	04	01	H7301_006_0	5	3	Out of Network Fitness-Non-gym	10		000000000000000010000000	2		2			2		2		2							
H7301	006	0	1	04	01	H7301_006_0	5	4	Out of Network Fitness-Gym	10		000000000000000010000000	2		1	50.00	50.00	2		2		2							
H7301	006	0	1	04	01	H7301_006_0	5	5	OON MCR Diagnostic Procedues/Tests/Lab	11	0000000000000001111100000000000100100	000000000000000000001000	2		2			2		1	1	1	50	50	50	50	2		
H7301	007	0	1	04	01	H7301_007_0	5	5	OON Services That Apply Additional Cost	11	0000000000000001111100000000000100100	000000000000000000001000	2		2			2		1	1	1	40	50	40	50	2		
H7301	007	0	1	04	01	H7301_007_0	5	4	Out of Network Fitness-Gym	10		000000000000000010000000	2		1	50.00	50.00	2		2		2							
H7301	007	0	1	04	01	H7301_007_0	5	3	Out of Network Fitness-Non-gym	10		000000000000000010000000	2		2			2		2		2							
H7301	007	0	1	04	01	H7301_007_0	5	2	Out of Network Copay Group 1	01	0000000000000000000000001000000000000		2		1	300.00	300.00	2		2		2							
H7301	007	0	1	04	01	H7301_007_0	5	1	Out of Network Coinsuance Group 1	11	0111111111111110000011110111111011011	000000100000000000000010	2		2			2		2		1		50		50			
H7301	008	0	1	04	01	H7301_008_0	4	4	NMCR Dental	10		000000000000000000100000	1	150.00	2			2		2		1		0		0			
H7301	008	0	1	04	01	H7301_008_0	4	3	Fitness	10		000000000000000010000000	2		1	50.00	50.00	2		2		2							
H7301	008	0	1	04	01	H7301_008_0	4	5	NMCR Eyewear	10		000000000000000000000100	1	150.00	2			2		2		1		0		0			
H7301	008	0	1	04	01	H7301_008_0	4	1	20% OON	11	0111111111111111111111110111111111111	000000100000000100000000	2		2			2		2		1		20		20			
H7301	008	0	1	04	01	H7301_008_0	4	2	Ambulance	01	0000000000000000000000001000000000000		2		1	100.00	100.00	2		2		2							
H7301	801	0	1	04	01	H7301_801_0	2	2	Mental Health	01	0000000000100100000000000000000000000		2		2			2		2		1		35		35			
H7301	801	0	1	04	01	H7301_801_0	2	3	Medicare Covered	01	0111101111011011111111111111101111111		2		2			2		2		1		20		20			
H7301	801	0	1	04	01	H7301_801_0	2	1	Home Health and Preventive Services	01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H7301	803	0	1	04	01	H7301_803_0	2	1	Home Health and Preventive Services	01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H7301	803	0	1	04	01	H7301_803_0	2	2	Mental Health	01	0000000000100100000000000000000000000		2		2			2		2		1		35		35			
H7301	803	0	1	04	01	H7301_803_0	2	3	Medicare Covered	01	0111101111011011111111111111101111111		2		2			2		2		1		20		20			
H7306	001	0	1	04	01	H7306_001_0	13	8	Group 8	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H7306	001	0	1	04	01	H7306_001_0	13	7	Group 7	10		000000000000000000010000	1	500.00	1	45.00	45.00	2		2		2							
H7306	001	0	1	04	01	H7306_001_0	13	6	Group 6	10		000000000000000000100000	2		2			2		2		2							
H7306	001	0	1	04	01	H7306_001_0	13	5	Group 5	10		000000000000000000000100	1	100.00	2			2		1	1	2	40		40		2		
H7306	001	0	1	04	01	H7306_001_0	13	3	Group 3	01	0000000000000000000000001000000000000		2		1	350.00	350.00	2		2		2							
H7306	001	0	1	04	01	H7306_001_0	13	2	Group 2	11	0000010000000000000000000000000001110	000000000000000000001000	2		1	0.00	0.00	2		2		2							
H7306	001	0	1	04	01	H7306_001_0	13	1	Group 1	01	0111101111111111111111110111011110001		2		2			2		2		1		40		40			
H7306	001	0	1	04	01	H7306_001_0	13	4	Group 4	10		000000100000000010000000	2		2			2		1	1	2	40		40		2		
H7306	801	0	1	04	01	H7306_801_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H7306	801	0	1	04	01	H7306_801_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H7306	803	0	1	04	01	H7306_803_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H7306	803	0	1	04	01	H7306_803_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H7728	002	0	1	04	01	H7728_002_0	15	12	$0 copayment	01	0000000000000000000000000000000001100		2		1	0.00	0.00	2		2		2							
H7728	002	0	1	04	01	H7728_002_0	15	11	$0-30%	01	0000000000000000000000000000010000000		2		1	0.00	0.00	2		2		1		30		30			
H7728	002	0	1	04	01	H7728_002_0	15	9	40% coinsurance	01	0000000000000000000000000100000000000		2		2			2		2		1		40		40			
H7728	002	0	1	04	01	H7728_002_0	15	8	$275 copayment	01	0000000000000000000000001000000000000		2		1	275.00	275.00	2		2		2							
H7728	002	0	1	04	01	H7728_002_0	15	7	35%, $50-$65	01	0000000000000000000010000000000000000		2		1	50.00	65.00	2		2		1		35		35			
H7728	002	0	1	04	01	H7728_002_0	15	6	35% coinsurance	01	0000000000000001111101000000000000000		2		2			2		2		1		35		35			
H7728	002	0	1	04	01	H7728_002_0	15	5	$45 copayment	01	0000000100000000000000000000000000000		2		1	45.00	45.00	2		2		2							
H7728	002	0	1	04	01	H7728_002_0	15	4	$50 copayment	01	0000001000001000000000000000000000000		2		1	50.00	50.00	2		2		2							
H7728	002	0	1	04	01	H7728_002_0	15	3	30% coinsurance	11	0000110000000000000000010011001110011	000000100000000100000000	2		2			2		2		1		30		30			
H7728	002	0	1	04	01	H7728_002_0	15	2	$65 copayment	01	0111000011110110000000100000000000000		2		1	65.00	65.00	2		2		2							
H7728	002	0	1	04	01	H7728_002_0	15	14	17A Eye Exams	10		000000000000000000001000	1	69.00	1	0.00	0.00	2		2		2							
H7728	002	0	1	04	01	H7728_002_0	15	13	20%	10		000000000000000000100000	2		2			2		2		1		20		20			
H7728	002	0	1	04	01	H7728_002_0	15	1	$0	10		000000000000000010000000	2		1	0.00	0.00	2		2		2							
H7728	002	0	1	04	01	H7728_002_0	15	10	20%	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H7728	801	0	1	04	01	H7728_801_0	7	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H7728	801	0	1	04	01	H7728_801_0	7	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H7728	802	0	1	04	01	H7728_802_0	6	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H7728	802	0	1	04	01	H7728_802_0	6	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H7728	803	0	1	04	01	H7728_803_0	6	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H7728	803	0	1	04	01	H7728_803_0	6	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H7787	001	0	1	04	01	H7787_001_0	3	8	50% Coinsurance	01	0000000000000001111100000000000000000		2		2			2		1	2	1		50		50	1	40.00	60.00
H7787	001	0	1	04	01	H7787_001_0	3	9	$0 Copay	10		000000000000000010000000	2		2			2		2		2							
H7787	001	0	1	04	01	H7787_001_0	3	2	$40 Copay	01	0000011000000000000000000000000000000		2		1	40.00	40.00	2		2		2							
H7787	001	0	1	04	01	H7787_001_0	3	11	0%-30% Coinsurance	10		000000000000000000000100	1	100.00	2			2		2		1		0		30			
H7787	001	0	1	04	01	H7787_001_0	3	7	0%-30% Coinsurance	01	0000000000000000000000000000000000010		2		2			2		2		1		0		30			
H7787	001	0	1	04	01	H7787_001_0	3	6	$0-$60 Copay	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	0.00	60.00	2		2		2							
H7787	001	0	1	04	01	H7787_001_0	3	5	$40-60 Copay	01	0000000000000000000000000000011100001		2		1	40.00	60.00	2		2		2							
H7787	001	0	1	04	01	H7787_001_0	3	3	$60 Copay	01	0000000111011010000000000000000000000		2		1	60.00	60.00	2		2		2							
H7787	001	0	1	04	01	H7787_001_0	3	10	30% Coinsurance	01	0000000000000000000000000000000011000		2		2			2		2		1		30		30			
H7787	001	0	1	04	01	H7787_001_0	3	1	50% Coinsurance	11	0111100000100100000011110111100000000	000000100000000000100000	2		2			2		2		1		50		50			
H7787	001	0	1	04	01	H7787_001_0	3	4	$50 Copay/20% Coinsurance	01	0000000000000000000000001000000000000		2		1	50.00	50.00	2		2		1		20		20			
H7787	002	0	1	04	01	H7787_002_0	3	2	$40 Copay	01	0000011000000000000000000000000000000		2		1	40.00	40.00	2		2		2							
H7787	002	0	1	04	01	H7787_002_0	3	11	25% Coinsurance	01	0000000000000000000000000000000010000		2		2			2		2		1		25		25			
H7787	002	0	1	04	01	H7787_002_0	3	10	50% Coinsurance	10		000000000000000000100000	2		2			2		2		1		50		50			
H7787	002	0	1	04	01	H7787_002_0	3	1	30% Coinsurance	11	0111100000100100000011110111100001000	000000100000000000000000	2		2			2		2		1		30		30			
H7787	002	0	1	04	01	H7787_002_0	3	9	$0 Copay	10		000000000000000010000000	2		2			2		2		2							
H7787	002	0	1	04	01	H7787_002_0	3	8	30% Coinsurance	01	0000000000000001111100000000000000000		2		2			2		1	2	1		30		30	1	40.00	60.00
H7787	002	0	1	04	01	H7787_002_0	3	7	0%-30%	01	0000000000000000000000000000000000010		2		2			2		2		1		0		30			
H7787	002	0	1	04	01	H7787_002_0	3	6	$0-$60	01	0000000000000000000000000000000000100		2		1	0.00	60.00	2		2		2							
H7787	002	0	1	04	01	H7787_002_0	3	3	$60 Copay	01	0000000111011010000000000000000000000		2		1	60.00	60.00	2		2		2							
H7787	002	0	1	04	01	H7787_002_0	3	4	$50 Copay/20% Coinsurance	01	0000000000000000000000001000000000000		2		1	50.00	50.00	2		2		1		20		20			
H7787	002	0	1	04	01	H7787_002_0	3	5	$40-$60 Copay	01	0000000000000000000000000000011100001		2		1	40.00	60.00	2		2		2							
H7917	008	0	1	04	01	H7917_008_0	7	1	50% Cost Share Group	01	0111111111111111111111100110010011000		2		2			2		2		1		50		50			
H7917	008	0	1	04	01	H7917_008_0	7	2	Ambulance	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H7917	008	0	1	04	01	H7917_008_0	7	3	$0 Cost Share	11	0000000000000000000000010000000000010	000000100000000010000000	2		2			2		2		2							
H7917	008	0	1	04	01	H7917_008_0	7	4	$30 Cost Share	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	30.00	30.00	2		2		2							
H7917	008	0	1	04	01	H7917_008_0	7	5	20% Cost Share	01	0000000000000000000000000001101000000		2		2			2		2		1		20		20			
H7917	008	0	1	04	01	H7917_008_0	7	6	$15 Copay	11	0000000000000000000000000000000000001	000000000000000000000010	2		1	15.00	15.00	2		2		2							
H7917	008	0	1	04	01	H7917_008_0	7	7	20% Cost Share w/ OV	01	0000000000000000000000000000000100000		2		2			2		1	1	1	50	20	50	20	2		
H7917	008	0	1	04	01	H7917_008_0	7	8	Eyewear Non Med Cov OON Ben Max	10		000000000000000000000100	1	175.00	2			2		2		2							
H7917	009	0	1	04	01	H7917_009_0	7	3	$0 Cost Share	11	0000000000000000000000010000000000010	000000100000000010000000	2		2			2		2		2							
H7917	009	0	1	04	01	H7917_009_0	7	2	Ambulance	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H7917	009	0	1	04	01	H7917_009_0	7	1	50% Cost Share Group	01	0111111111111111111111100110010011000		2		2			2		2		1		50		50			
H7917	009	0	1	04	01	H7917_009_0	7	4	$30 Cost Share	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	30.00	30.00	2		2		2							
H7917	009	0	1	04	01	H7917_009_0	7	8	Eyewear Non Med Cov OON Ben Max	10		000000000000000000000100	1	175.00	2			2		2		2							
H7917	009	0	1	04	01	H7917_009_0	7	7	20% Cost Share w/ OV	01	0000000000000000000000000000000100000		2		2			2		1	1	1	50	20	50	20	2		
H7917	009	0	1	04	01	H7917_009_0	7	6	$15 Copay	11	0000000000000000000000000000000000001	000000000000000000000010	2		1	15.00	15.00	2		2		2							
H7917	009	0	1	04	01	H7917_009_0	7	5	20% Cost Share	01	0000000000000000000000000001101000000		2		2			2		2		1		20		20			
H7917	010	0	1	04	01	H7917_010_0	7	1	50% Cost Share Group	01	0111111111111111111111100110010011000		2		2			2		2		1		50		50			
H7917	010	0	1	04	01	H7917_010_0	7	2	Ambulance	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H7917	010	0	1	04	01	H7917_010_0	7	3	$0 Cost Share	11	0000000000000000000000010000000000010	000000100000000010000000	2		2			2		2		2							
H7917	010	0	1	04	01	H7917_010_0	7	7	20% Cost Share w/ OV	01	0000000000000000000000000000000100000		2		2			2		1	1	1	50	20	50	20	2		
H7917	010	0	1	04	01	H7917_010_0	7	6	$15 Copay	11	0000000000000000000000000000000000001	000000000000000000000010	2		1	15.00	15.00	2		2		2							
H7917	010	0	1	04	01	H7917_010_0	7	5	20% Cost Share	01	0000000000000000000000000001101000000		2		2			2		2		1		20		20			
H7917	010	0	1	04	01	H7917_010_0	7	4	$30 Cost Share	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	30.00	30.00	2		2		2							
H7917	010	0	1	04	01	H7917_010_0	7	8	Eyewear Non Med Cov OON Ben Max	10		000000000000000000000100	1	175.00	2			2		2		2							
H7917	011	0	1	04	01	H7917_011_0	7	3	$0 Cost Share	11	0000000000000000000000010000000000010	000000100000000010000000	2		2			2		2		2							
H7917	011	0	1	04	01	H7917_011_0	7	2	Ambulance	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H7917	011	0	1	04	01	H7917_011_0	7	1	50% Cost Share Group	01	0111111111111111111111100110010011000		2		2			2		2		1		50		50			
H7917	011	0	1	04	01	H7917_011_0	7	4	$30 Cost Share	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	30.00	30.00	2		2		2							
H7917	011	0	1	04	01	H7917_011_0	7	8	Eyewear Non Med Cov OON Ben Max	10		000000000000000000000100	1	175.00	2			2		2		2							
H7917	011	0	1	04	01	H7917_011_0	7	7	20% Cost Share w/ OV	01	0000000000000000000000000000000100000		2		2			2		1	1	1	50	20	50	20	2		
H7917	011	0	1	04	01	H7917_011_0	7	6	$15 Copay	11	0000000000000000000000000000000000001	000000000000000000000010	2		1	15.00	15.00	2		2		2							
H7917	011	0	1	04	01	H7917_011_0	7	5	20% Cost Share	01	0000000000000000000000000001101000000		2		2			2		2		1		20		20			
H7917	012	0	1	04	01	H7917_012_0	8	3	$0 Cost Share	11	0000000000000000000000010000000000010	000000100000000010000000	2		2			2		2		2							
H7917	012	0	1	04	01	H7917_012_0	8	2	Ambulance	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H7917	012	0	1	04	01	H7917_012_0	8	1	50% Cost Share Group	01	0111111111111111111111100110010011000		2		2			2		2		1		50		50			
H7917	012	0	1	04	01	H7917_012_0	8	4	$40 Cost Share	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	40.00	40.00	2		2		2							
H7917	012	0	1	04	01	H7917_012_0	8	5	20% Cost Share	01	0000000000000000000000000001101000000		2		2			2		2		1		20		20			
H7917	012	0	1	04	01	H7917_012_0	8	6	$15 Copay	11	0000000000000000000000000000000000001	000000000000000000000010	2		1	15.00	15.00	2		2		2							
H7917	012	0	1	04	01	H7917_012_0	8	7	20% Cost Share w/ OV	01	0000000000000000000000000000000100000		2		2			2		1	1	1	50	20	50	20	2		
H7917	012	0	1	04	01	H7917_012_0	8	8	Eyewear Non Med Cov OON Ben Max	10		000000000000000000000100	1	175.00	2			2		2		2							
H7917	013	0	1	04	01	H7917_013_0	8	3	$0 Cost Share	11	0000000000000000000000010000000000010	000000100000000010000000	2		2			2		2		2							
H7917	013	0	1	04	01	H7917_013_0	8	2	Ambulance	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H7917	013	0	1	04	01	H7917_013_0	8	1	50% Cost Share Group	01	0111111111111111111111100110010011000		2		2			2		2		1		50		50			
H7917	013	0	1	04	01	H7917_013_0	8	4	$40 Cost Share	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	40.00	40.00	2		2		2							
H7917	013	0	1	04	01	H7917_013_0	8	8	Eyewear Non Med Cov OON Ben Max	10		000000000000000000000100	1	175.00	2			2		2		2							
H7917	013	0	1	04	01	H7917_013_0	8	7	20% Cost Share w/ OV	01	0000000000000000000000000000000100000		2		2			2		1	1	1	50	20	50	20	2		
H7917	013	0	1	04	01	H7917_013_0	8	6	$15 Copay	11	0000000000000000000000000000000000001	000000000000000000000010	2		1	15.00	15.00	2		2		2							
H7917	013	0	1	04	01	H7917_013_0	8	5	20% Cost Share	01	0000000000000000000000000001101000000		2		2			2		2		1		20		20			
H7917	014	0	1	04	01	H7917_014_0	8	1	50% Cost Share Group	01	0111111111111111111111100110010011000		2		2			2		2		1		50		50			
H7917	014	0	1	04	01	H7917_014_0	8	2	Ambulance	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H7917	014	0	1	04	01	H7917_014_0	8	3	$0 Cost Share	11	0000000000000000000000010000000000010	000000100000000010000000	2		2			2		2		2							
H7917	014	0	1	04	01	H7917_014_0	8	4	$40 Cost Share	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	40.00	40.00	2		2		2							
H7917	014	0	1	04	01	H7917_014_0	8	5	20% Cost Share	01	0000000000000000000000000001101000000		2		2			2		2		1		20		20			
H7917	014	0	1	04	01	H7917_014_0	8	6	$15 Copay	11	0000000000000000000000000000000000001	000000000000000000000010	2		1	15.00	15.00	2		2		2							
H7917	014	0	1	04	01	H7917_014_0	8	7	20% Cost Share w/ OV	01	0000000000000000000000000000000100000		2		2			2		1	1	1	50	20	50	20	2		
H7917	014	0	1	04	01	H7917_014_0	8	8	Eyewear Non Med Cov OON Ben Max	10		000000000000000000000100	1	175.00	2			2		2		2							
H7917	015	0	1	04	01	H7917_015_0	8	3	$0 Cost Share	11	0000000000000000000000010000000000010	000000100000000010000000	2		2			2		2		2							
H7917	015	0	1	04	01	H7917_015_0	8	4	$40 Cost Share	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	40.00	40.00	2		2		2							
H7917	015	0	1	04	01	H7917_015_0	8	5	20% Cost Share	01	0000000000000000000000000001101000000		2		2			2		2		1		20		20			
H7917	015	0	1	04	01	H7917_015_0	8	6	$15 Copay	11	0000000000000000000000000000000000001	000000000000000000000010	2		1	15.00	15.00	2		2		2							
H7917	015	0	1	04	01	H7917_015_0	8	7	20% Cost Share w/ OV	01	0000000000000000000000000000000100000		2		2			2		1	1	1	50	20	50	20	2		
H7917	015	0	1	04	01	H7917_015_0	8	8	Eyewear Non Med Cov OON Ben Max	10		000000000000000000000100	1	175.00	2			2		2		2							
H7917	015	0	1	04	01	H7917_015_0	8	1	50% Cost Share Group	01	0111111111111111111111100110010011000		2		2			2		2		1		50		50			
H7917	015	0	1	04	01	H7917_015_0	8	2	Ambulance	01	0000000000000000000000001000000000000		2		1	150.00	150.00	2		2		2							
H7917	030	0	1	04	01	H7917_030_0	7	6	$15 Copay	11	0000000000000000000000000000000000001	000000000000000000000010	2		1	15.00	15.00	2		2		2							
H7917	030	0	1	04	01	H7917_030_0	7	5	20% Cost Share	01	0000000000000000000000000001101000000		2		2			2		2		1		20		20			
H7917	030	0	1	04	01	H7917_030_0	7	8	Eyewear Non Med Cov OON Ben Max	10		000000000000000000000100	1	100.00	2			2		2		2							
H7917	030	0	1	04	01	H7917_030_0	7	7	20% Cost Share w/ OV	01	0000000000000000000000000000000100000		2		2			2		1	1	1	50	20	50	20	2		
H7917	030	0	1	04	01	H7917_030_0	7	1	50% Cost Share Group	01	0111111111111111111111100110010011000		2		2			2		2		1		50		50			
H7917	030	0	1	04	01	H7917_030_0	7	2	Ambulance	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H7917	030	0	1	04	01	H7917_030_0	7	3	$0 Cost Share	11	0000000000000000000000010000000000010	000000100000000010000000	2		2			2		2		2							
H7917	030	0	1	04	01	H7917_030_0	7	4	$40 Cost Share	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	40.00	40.00	2		2		2							
H7917	031	0	1	04	01	H7917_031_0	7	1	50% Cost Share Group	01	0111111111111111111111100110010011000		2		2			2		2		1		50		50			
H7917	031	0	1	04	01	H7917_031_0	7	7	20% Cost Share w/ OV	01	0000000000000000000000000000000100000		2		2			2		1	1	1	50	20	50	20	2		
H7917	031	0	1	04	01	H7917_031_0	7	6	$15 Copay	11	0000000000000000000000000000000000001	000000000000000000000010	2		1	15.00	15.00	2		2		2							
H7917	031	0	1	04	01	H7917_031_0	7	5	20% Cost Share	01	0000000000000000000000000001101000000		2		2			2		2		1		20		20			
H7917	031	0	1	04	01	H7917_031_0	7	4	$40 Cost Share	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	40.00	40.00	2		2		2							
H7917	031	0	1	04	01	H7917_031_0	7	3	$0 Cost Share	11	0000000000000000000000010000000000010	000000100000000010000000	2		2			2		2		2							
H7917	031	0	1	04	01	H7917_031_0	7	2	Ambulance	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H7917	031	0	1	04	01	H7917_031_0	7	8	Eyewear Non Med Cov OON Ben Max	10		000000000000000000000100	1	100.00	2			2		2		2							
H7917	032	0	1	04	01	H7917_032_0	7	6	$15 Copay	11	0000000000000000000000000000000000001	000000000000000000000010	2		1	15.00	15.00	2		2		2							
H7917	032	0	1	04	01	H7917_032_0	7	5	20% Cost Share	01	0000000000000000000000000001101000000		2		2			2		2		1		20		20			
H7917	032	0	1	04	01	H7917_032_0	7	4	$40 Cost Share	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	40.00	40.00	2		2		2							
H7917	032	0	1	04	01	H7917_032_0	7	3	$0 Cost Share	11	0000000000000000000000010000000000010	000000100000000010000000	2		2			2		2		2							
H7917	032	0	1	04	01	H7917_032_0	7	2	Ambulance	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H7917	032	0	1	04	01	H7917_032_0	7	1	50% Cost Share Group	01	0111111111111111111111100110010011000		2		2			2		2		1		50		50			
H7917	032	0	1	04	01	H7917_032_0	7	7	20% Cost Share w/ OV	01	0000000000000000000000000000000100000		2		2			2		1	1	1	50	20	50	20	2		
H7917	032	0	1	04	01	H7917_032_0	7	8	Eyewear Non Med Cov OON Ben Max	10		000000000000000000000100	1	100.00	2			2		2		2							
H7917	033	0	1	04	01	H7917_033_0	7	1	50% Cost Share Group	01	0111111111111111111111100110010011000		2		2			2		2		1		50		50			
H7917	033	0	1	04	01	H7917_033_0	7	2	Ambulance	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H7917	033	0	1	04	01	H7917_033_0	7	3	$0 Cost Share	11	0000000000000000000000010000000000010	000000100000000010000000	2		2			2		2		2							
H7917	033	0	1	04	01	H7917_033_0	7	4	$40 Cost Share	11	0000000000000000000000000000000000100	000000000000000000001000	2		1	40.00	40.00	2		2		2							
H7917	033	0	1	04	01	H7917_033_0	7	5	20% Cost Share	01	0000000000000000000000000001101000000		2		2			2		2		1		20		20			
H7917	033	0	1	04	01	H7917_033_0	7	8	Eyewear Non Med Cov OON Ben Max	10		000000000000000000000100	1	100.00	2			2		2		2							
H7917	033	0	1	04	01	H7917_033_0	7	6	$15 Copay	11	0000000000000000000000000000000000001	000000000000000000000010	2		1	15.00	15.00	2		2		2							
H7917	033	0	1	04	01	H7917_033_0	7	7	20% Cost Share w/ OV	01	0000000000000000000000000000000100000		2		2			2		1	1	1	50	20	50	20	2		
H7917	801	0	1	04	01	H7917_801_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H7917	801	0	1	04	01	H7917_801_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H7917	802	0	1	04	01	H7917_802_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H7917	802	0	1	04	01	H7917_802_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H7917	803	0	1	04	01	H7917_803_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H7917	803	0	1	04	01	H7917_803_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H7971	001	0	1	04	01	H7971_001_0	10	1		11	0111111111111111111111111111111111111	000000100000000000001000	2		2			2		2		1		35		35			
H7971	001	0	1	04	01	H7971_001_0	10	2		10		000000000000000000000100	1	100.00	2			2		2		2							
H7971	801	0	1	04	01	H7971_801_0	8	1		11	0111111111111111111111111111111111111	000000100000000000001000	2		2			2		2		1		35		35			
H7971	801	0	1	04	01	H7971_801_0	8	3		10		000000000000000000000100	1	100.00	2			2		2		2							
H7971	801	0	1	04	01	H7971_801_0	8	2		10		000000000000000010000000	2		2			2		2		2							
H7971	802	0	1	04	01	H7971_802_0	7	2		10		000000000000000010000000	2		2			2		2		2							
H7971	802	0	1	04	01	H7971_802_0	7	1		11	0111111111111111111111111111111111111	000000100000000000001000	2		2			2		2		1		35		35			
H7971	802	0	1	04	01	H7971_802_0	7	3		10		000000000000000000000100	1	100.00	2			2		2		2							
H8064	002	0	1	04	01	H8064_002_0	6	10	25 PCT Coinsurance	01	0000000000000000000000100000000000000		2		2			2		2		1		25		25			
H8064	002	0	1	04	01	H8064_002_0	6	1	20 PCT COINSURANCE	01	0000100000000000000001000111100010010		2		2			2		2		1		20		20			
H8064	002	0	1	04	01	H8064_002_0	6	9	200 Copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H8064	002	0	1	04	01	H8064_002_0	6	8	150 Copay, 20 - 25 PCT	01	0000000000000000010010000000000000000		2		1	150.00	150.00	2		2		1		20		25			
H8064	002	0	1	04	01	H8064_002_0	6	7	20 to 45 Copay, 20 COINS	01	0000000000000000001000000000000000000		2		1	20.00	45.00	2		2		1		20		20			
H8064	002	0	1	04	01	H8064_002_0	6	6	20 to 45 Copay, 25 PCT Coinsurance	01	0000000000000001100000000000000000000		2		1	20.00	45.00	2		2		1		25		25			
H8064	002	0	1	04	01	H8064_002_0	6	5	0 Copay - Med Covered	11	0000000000000000000000000000011100000	000000000000000100000000	2		1	0.00	0.00	2		2		2							
H8064	002	0	1	04	01	H8064_002_0	6	11	20 Copay	01	0000001100000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H8064	002	0	1	04	01	H8064_002_0	6	12	0 - 45 Copay	01	0000000000000000000000000000000000100		2		1	0.00	45.00	2		2		2							
H8064	002	0	1	04	01	H8064_002_0	6	13	15 PCT Coinsurance	01	0000010000000000000000000000000000000		2		2			2		2		1		15		15			
H8064	002	0	1	04	01	H8064_002_0	6	14	0 Copay - Supplemental	10		000000000000000010000000	1	500.00	2			2		2		2							
H8064	002	0	1	04	01	H8064_002_0	6	15	45 Copay - Supplemental	10		000000000000000000001000	1	100.00	1	45.00	45.00	2		2		2							
H8064	002	0	1	04	01	H8064_002_0	6	2	45 COPAY	01	0000000011111110000000010000000001001		2		1	45.00	45.00	2		2		2							
H8064	002	0	1	04	01	H8064_002_0	6	3	20 to 45 Copay or 20 to 25 PCT	01	0000000000000000000100000000000000000		2		1	20.00	45.00	2		2		1		20		25			
H8064	002	0	1	04	01	H8064_002_0	6	4	20 Copay or 25 PCT Coinsurance	01	0111000000000000000000000000000000000		2		1	20.00	20.00	2		2		1		25		25			
H8091	002	0	1	04	01	H8091_002_0	11	1	All Other	11	0111111111111110000011110111101011111	000000000000000100001000	2		2			2		2		1		30		30			
H8091	002	0	1	04	01	H8091_002_0	11	2	Education/Wellness Programs	10		000000000000000010000000	2		2			1	250.00	2		1		50		50			
H8091	002	0	1	04	01	H8091_002_0	11	4	Laboratory Services	01	0000000000000000100000000000000000000		2		2			2		2		1		0		30			
H8091	002	0	1	04	01	H8091_002_0	11	5	Diagnostic	01	0000000000000001011100000000000100000		2		2			2		1	1	1	30	30	30	30	2		
H8091	002	0	1	04	01	H8091_002_0	11	6	Preventive	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H8091	002	0	1	04	01	H8091_002_0	11	3	Ambulance	01	0000000000000000000000001000000000000		2		1	350.00	350.00	2		2		2							
H8091	004	0	1	04	01	H8091_004_0	10	2	Education/Wellness Programs	10		000000000000000010000000	2		2			1	250.00	2		1		50		50			
H8091	004	0	1	04	01	H8091_004_0	10	1	All Other	11	0111111111111110000011110111101011111	000000000000000100001000	2		2			2		2		1		30		30			
H8091	004	0	1	04	01	H8091_004_0	10	6	Preventive	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H8091	004	0	1	04	01	H8091_004_0	10	3	Ambulance	01	0000000000000000000000001000000000000		2		1	350.00	350.00	2		2		2							
H8091	004	0	1	04	01	H8091_004_0	10	4	Laboratory Services	01	0000000000000000100000000000000000000		2		2			2		2		1		0		30			
H8091	004	0	1	04	01	H8091_004_0	10	5	Diagnostic	01	0000000000000001011100000000000100000		2		2			2		1	1	1	30	30	30	30	2		
H8145	003	0	1	09	04	H8145_003_0	4	7		01	0000100000100100000000000000000000000		2		1	40.00	40.00	2		2		2							
H8145	003	0	1	09	04	H8145_003_0	4	9		01	0000000000000000000000100000000000000		2		1	95.00	95.00	2		2		2							
H8145	003	0	1	09	04	H8145_003_0	4	5		01	0000000000000000000100000000000000000		2		1	15.00	95.00	2		2		2							
H8145	003	0	1	09	04	H8145_003_0	4	4		01	0111001110000010000000000000000000000		2		1	15.00	40.00	2		2		2							
H8145	003	0	1	09	04	H8145_003_0	4	3		01	0000000000000001100000000000000000000		2		1	0.00	95.00	2		2		2							
H8145	003	0	1	09	04	H8145_003_0	4	2		01	0000000000000000000000000000000000100		2		1	0.00	45.00	2		2		2							
H8145	003	0	1	09	04	H8145_003_0	4	15		10		000000000100000000000000	1	30.00	2			2		2		1		50		50			
H8145	003	0	1	09	04	H8145_003_0	4	14		10		000000000010000010000000	2		2			2		2		1		50		50			
H8145	003	0	1	09	04	H8145_003_0	4	13		01	0000000000000000001000000000000000000		2		1	45.00	45.00	2		2		1		20		20			
H8145	003	0	1	09	04	H8145_003_0	4	12		01	0000000000000000000010000000000000000		2		1	40.00	270.00	2		2		1		20		20			
H8145	003	0	1	09	04	H8145_003_0	4	11		01	0000000000000000000000000000100010000		2		2			2		2		1		20		20			
H8145	003	0	1	09	04	H8145_003_0	4	10		01	0000000000000000000000000111000000000		2		2			2		2		1		18		18			
H8145	003	0	1	09	04	H8145_003_0	4	1		11	0000010000000000000000010000011100000	000000100000000100000000	2		1	0.00	0.00	2		2		2							
H8145	003	0	1	09	04	H8145_003_0	4	8		01	0000000001011000000000000000000001011		2		1	45.00	45.00	2		2		2							
H8145	003	0	1	09	04	H8145_003_0	4	6		01	0000000000000000010001001000000000000		2		1	220.00	270.00	2		2		2							
H8145	004	0	1	09	04	H8145_004_0	3	1		11	0000010000000000000000010000011100000	000000100000000100000000	2		1	0.00	0.00	2		2		2							
H8145	004	0	1	09	04	H8145_004_0	3	10		01	0000000000000000000000100000000000000		2		1	95.00	95.00	2		2		2							
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H8552	022	0	1	04	01	H8552_022_0	15	6	$0 Copayment	01	0000000000000000000000000000000001110		2		1	0.00	0.00	2		2		2							
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H8552	024	0	1	04	01	H8552_024_0	16	6	$0 Copayment	01	0000000000000000000000000000000001110		2		1	0.00	0.00	2		2		2							
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H8552	024	0	1	04	01	H8552_024_0	16	3	$30 Copayment Group	01	0000000100010000000000000000000000000		2		1	30.00	30.00	2		2		2							
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H8552	027	0	1	04	01	H8552_027_0	15	10	$0 Copay Group with $69 Max Benefit	10		000000000000000000001000	1	69.00	1	0.00	0.00	2		2		2							
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H8552	027	0	1	04	01	H8552_027_0	15	4	$200 Copayment Group	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H8552	027	0	1	04	01	H8552_027_0	15	5	20% OON Coinsurance Group	11	0000000000000000000000000111100010000	000000000000000000100000	2		2			2		2		1		20		20			
H8552	027	0	1	04	01	H8552_027_0	15	6	$0 Copayment	01	0000000000000000000000000000000001110		2		1	0.00	0.00	2		2		2							
H8552	027	0	1	04	01	H8552_027_0	15	7	$0 - 30% OON Group	01	0000000000000001000000000000010000000		2		1	0.00	0.00	2		2		1		30		30			
H8552	027	0	1	04	01	H8552_027_0	15	8	$35 OON Copayment Group	01	0000000001010000000000000000000000000		2		1	35.00	35.00	2		2		2							
H8552	027	0	1	04	01	H8552_027_0	15	9	0% - 50% Coinsurance Group	10		000000000000000010000000	2		2			2		2		1		0		50			
H8552	027	0	1	04	01	H8552_027_0	15	2	$20 OON Copayment Group	01	0000001000001000000000000000000000000		2		1	20.00	20.00	2		2		2							
H8552	801	0	1	04	01	H8552_801_0	5	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H8552	801	0	1	04	01	H8552_801_0	5	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H8552	802	0	1	04	01	H8552_802_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H8552	802	0	1	04	01	H8552_802_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H8552	803	0	1	04	01	H8552_803_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H8552	803	0	1	04	01	H8552_803_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H8604	007	1	1	04	01	H8604_007_1	5	3	Group 3	01	0000001000000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H8604	007	1	1	04	01	H8604_007_1	5	2	Group 2	01	0000000000000000000000000111000000000		2		2			2		2		1		30		30			
H8604	007	1	1	04	01	H8604_007_1	5	1	Group 1	11	0111110000000000011111010000111010010	000000100000000010000000	2		2			2		2		1		20		20			
H8604	007	1	1	04	01	H8604_007_1	5	4	Group 4	11	0000000111111110000000100000000001001	000001000000000000001000	2		1	45.00	45.00	2		2		2							
H8604	007	1	1	04	01	H8604_007_1	5	5	Group 5	01	0000000000000000000000001000000000000		2		1	125.00	125.00	2		2		2							
H8604	007	1	1	04	01	H8604_007_1	5	6	Group 6	10		000000000000000000000100	1	100.00	2			2		2		1		20		20			
H8604	007	1	1	04	01	H8604_007_1	5	7	Group 7	01	0000000000000001100000000000000100000		2		2			2		1	2	1		20		20	1	45.00	45.00
H8604	007	1	1	04	01	H8604_007_1	5	8	Group 8	01	0000000000000000000000000000000000100		2		1	20.00	45.00	2		1	2	2					1	20.00	45.00
H8604	007	2	1	04	01	H8604_007_2	5	3	Group 3	01	0000001000000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H8604	007	2	1	04	01	H8604_007_2	5	2	Group 2	01	0000000000000000000000000111000000000		2		2			2		2		1		30		30			
H8604	007	2	1	04	01	H8604_007_2	5	1	Group 1	11	0111110000000000011111010000111010010	000000100000000010000000	2		2			2		2		1		20		20			
H8604	007	2	1	04	01	H8604_007_2	5	4	Group 4	11	0000000111111110000000100000000001001	000001000000000000001000	2		1	45.00	45.00	2		2		2							
H8604	007	2	1	04	01	H8604_007_2	5	8	Group 8	01	0000000000000000000000000000000000100		2		1	20.00	45.00	2		1	2	2					1	20.00	45.00
H8604	007	2	1	04	01	H8604_007_2	5	7	Group 7	01	0000000000000001100000000000000100000		2		2			2		1	2	1		20		20	1	45.00	45.00
H8604	007	2	1	04	01	H8604_007_2	5	6	Group 6	10		000000000000000000000100	1	100.00	2			2		2		1		20		20			
H8604	007	2	1	04	01	H8604_007_2	5	5	Group 5	01	0000000000000000000000001000000000000		2		1	125.00	125.00	2		2		2							
H8604	008	1	1	04	01	H8604_008_1	4	1	Group 1	11	0111110000000000011111010000111010010	000000100000000010000000	2		2			2		2		1		20		20			
H8604	008	1	1	04	01	H8604_008_1	4	2	Group 2	01	0000000000000000000000000111000000000		2		2			2		2		1		30		30			
H8604	008	1	1	04	01	H8604_008_1	4	3	Group 3	01	0000001000000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H8604	008	1	1	04	01	H8604_008_1	4	7	Group 7	01	0000000000000001100000000000000100000		2		2			2		1	2	1		20		20	1	45.00	45.00
H8604	008	1	1	04	01	H8604_008_1	4	6	Group 6	10		000000000000000000000100	1	100.00	2			2		2		1		20		20			
H8604	008	1	1	04	01	H8604_008_1	4	5	Group 5	01	0000000000000000000000001000000000000		2		1	125.00	125.00	2		2		2							
H8604	008	1	1	04	01	H8604_008_1	4	4	Group 4	11	0000000111111110000000100000000001001	000001000000000000001000	2		1	45.00	45.00	2		2		2							
H8604	008	1	1	04	01	H8604_008_1	4	8	Group 8	01	0000000000000000000000000000000000100		2		1	20.00	45.00	2		1	2	2					1	20.00	45.00
H8604	008	2	1	04	01	H8604_008_2	4	1	Group 1	11	0111110000000000011111010000111010010	000000100000000010000000	2		2			2		2		1		20		20			
H8604	008	2	1	04	01	H8604_008_2	4	2	Group 2	01	0000000000000000000000000111000000000		2		2			2		2		1		30		30			
H8604	008	2	1	04	01	H8604_008_2	4	3	Group 3	01	0000001000000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H8604	008	2	1	04	01	H8604_008_2	4	4	Group 4	11	0000000111111110000000100000000001001	000001000000000000001000	2		1	45.00	45.00	2		2		2							
H8604	008	2	1	04	01	H8604_008_2	4	5	Group 5	01	0000000000000000000000001000000000000		2		1	125.00	125.00	2		2		2							
H8604	008	2	1	04	01	H8604_008_2	4	6	Group 6	10		000000000000000000000100	1	100.00	2			2		2		1		20		20			
H8604	008	2	1	04	01	H8604_008_2	4	7	Group 7	01	0000000000000001100000000000000100000		2		2			2		1	2	1		20		20	1	45.00	45.00
H8604	008	2	1	04	01	H8604_008_2	4	8	Group 8	01	0000000000000000000000000000000000100		2		1	20.00	45.00	2		1	2	2					1	20.00	45.00
H8604	801	0	1	04	01	H8604_801_0	3	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H8604	801	0	1	04	01	H8604_801_0	3	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H8604	802	0	1	04	01	H8604_802_0	3	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H8604	802	0	1	04	01	H8604_802_0	3	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H8634	001	0	1	04	01	H8634_001_0	10	4	0 Copay/0 Coinsurance	11	0000000000000000000000010000000100000	000000000000000110000000	2		2			2		2		2							
H8634	001	0	1	04	01	H8634_001_0	10	3	20% Coinsurance	01	0000000000000000000000000000100010000		2		2			2		2		1		20		20			
H8634	001	0	1	04	01	H8634_001_0	10	5	Vision Eye Exam	10		000000000000000000001000	1	40.00	2			2		2		2							
H8634	001	0	1	04	01	H8634_001_0	10	6	Vision Eyewear - Frames	10		000000000000000000000100	1	100.00	2			2		2		2							
H8634	001	0	1	04	01	H8634_001_0	10	2	$200 Copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H8634	001	0	1	04	01	H8634_001_0	10	8	Hearing Aids	10		000000000000000000000001	1	1000.00	2			2		2		2							
H8634	001	0	1	04	01	H8634_001_0	10	7	Preventive Dental	10		000000000000000000100000	2		1	5.00	5.00	2		2		2							
H8634	001	0	1	04	01	H8634_001_0	10	1	30% Coinsurance	11	0111111111111111111111100111011001111	000000000000000000000010	2		2			2		2		1		30		30			
H8634	002	0	1	04	01	H8634_002_0	12	3	20% Coinsurance	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H8634	002	0	1	04	01	H8634_002_0	12	2	$200 Copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H8634	002	0	1	04	01	H8634_002_0	12	1	40% Coinsurance	01	0111111111111111111111110111011011111		2		2			2		2		1		40		40			
H8634	002	0	1	04	01	H8634_002_0	12	5	Preventive Dental	10		000000000000000000100000	2		1	5.00	5.00	2		2		2							
H8634	002	0	1	04	01	H8634_002_0	12	4	$ 0 copay	11	0000000000000000000000000000000100000	000000000000000110000000	2		2			2		2		2							
H8634	003	0	1	04	01	H8634_003_0	14	3	20%	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
H8634	003	0	1	04	01	H8634_003_0	14	2	$200	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H8634	003	0	1	04	01	H8634_003_0	14	1	40%	01	0111111111111111111111100111011011111		2		2			2		2		1		40		40			
H8634	003	0	1	04	01	H8634_003_0	14	4	$0	11	0000000000000000000000010000000100000	000000000000000110000000	2		1	0.00	0.00	2		2		2							
H8634	004	0	1	04	01	H8634_004_0	15	4	$0 Copay	11	0000000000000000000000010000000100000	000000000000000110100000	2		2			2		2		2							
H8634	004	0	1	04	01	H8634_004_0	15	9	OTC Allowance	10		000000000100000000000000	1	30.00	2			2		2		2							
H8634	004	0	1	04	01	H8634_004_0	15	8	70% Coinsurance	10		000000000000000000010000	1	1000.00	2			2		2		1		0		70			
H8634	004	0	1	04	01	H8634_004_0	15	7	Hearing Aids	10		000000000000000000000001	1	1000.00	2			2		2		2							
H8634	004	0	1	04	01	H8634_004_0	15	6	Vision Eyewear - Frames	10		000000000000000000000100	1	100.00	2			2		2		2							
H8634	004	0	1	04	01	H8634_004_0	15	1	30% Coinsurance	11	0111111111111111111111110111011001111	000000000000000000000010	2		2			2		2		1		30		30			
H8634	004	0	1	04	01	H8634_004_0	15	5	Vision Eye Exam	10		000000000000000000001000	1	40.00	2			2		2		2							
H8634	004	0	1	04	01	H8634_004_0	15	3	20%	01	0000000000000000000000000000100010000		2		2			2		2		1		20		20			
H8634	004	0	1	04	01	H8634_004_0	15	2	$200	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H8634	005	0	1	04	01	H8634_005_0	13	9	$30/Month OTC	10		000000000100000000000000	1	30.00	2			2		2		2							
H8634	005	0	1	04	01	H8634_005_0	13	8	Preventive Dental	10		000000000000000000100000	2		2			2		2		2							
H8634	005	0	1	04	01	H8634_005_0	13	7	Hearing Aids	10		000000000000000000000001	1	1000.00	2			2		2		2							
H8634	005	0	1	04	01	H8634_005_0	13	6	Vision eyewear	10		000000000000000000000100	1	100.00	2			2		2		2							
H8634	005	0	1	04	01	H8634_005_0	13	3	20% Coinsurance	01	0000000000000000000000000000100010000		2		2			2		2		1		20		20			
H8634	005	0	1	04	01	H8634_005_0	13	4	0 Copay/ 0 Coinsurance	11	0000000000000000000000010000000100000	000000000000000110000000	2		1	0.00	0.00	2		2		2							
H8634	005	0	1	04	01	H8634_005_0	13	5	Vision Eye Exam	10		000000000000000000001000	1	40.00	2			2		2		2							
H8634	005	0	1	04	01	H8634_005_0	13	2	$200 Copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H8634	005	0	1	04	01	H8634_005_0	13	11	Comprehensive Dental	10		000000000000000000010000	1	1000.00	2			2		2		1		0		70			
H8634	005	0	1	04	01	H8634_005_0	13	10	40%	01	0000000000001000000000000000000000000		2		2			2		2		1		40		40			
H8634	005	0	1	04	01	H8634_005_0	13	1	30% Coinsurance	11	0111111111110111111111100111011001111	000000000000000000000010	2		2			2		2		1		30		30			
H8634	801	0	1	04	01	H8634_801_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H8634	801	0	1	04	01	H8634_801_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H8634	803	0	1	04	01	H8634_803_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H8634	803	0	1	04	01	H8634_803_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H8634	805	0	1	04	01	H8634_805_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H8634	805	0	1	04	01	H8634_805_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H8634	807	0	1	04	01	H8634_807_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H8634	807	0	1	04	01	H8634_807_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H8634	809	0	1	04	01	H8634_809_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H8634	809	0	1	04	01	H8634_809_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H8634	811	0	1	04	01	H8634_811_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H8634	811	0	1	04	01	H8634_811_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H8634	813	0	1	04	01	H8634_813_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H8634	813	0	1	04	01	H8634_813_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H8634	815	0	1	04	01	H8634_815_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H8634	815	0	1	04	01	H8634_815_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H8634	817	0	1	04	01	H8634_817_0	4	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H8634	817	0	1	04	01	H8634_817_0	4	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H8980	002	0	1	04	01	H8980_002_0	6	2	40% Coinsurance Group	01	0000000000000000000000000001000000000		2		2			2		2		1		40		40			
H8980	002	0	1	04	01	H8980_002_0	6	3	45% Coinsurance Group	01	0000100000100100000000100000000000000		2		2			2		2		1		45		45			
H8980	002	0	1	04	01	H8980_002_0	6	9	OON with separate office visit cost	01	0000000000000000000000000000000100000		2		2			2		1	1	1	30	30	30	30	2		
H8980	002	0	1	04	01	H8980_002_0	6	8	Non-Medicare Dental	10		000001100000000000001010	2		2			2		2		1		30		30			
H8980	002	0	1	04	01	H8980_002_0	6	1	30% Coins Medicare Covered Benefit	01	0111001111011011111111010110101011111		2		2			2		2		1		30		30			
H8980	002	0	1	04	01	H8980_002_0	6	6	Fitness	10		000000000000000010000000	2		1	50.00	50.00	2		2		2							
H8980	002	0	1	04	01	H8980_002_0	6	5	Ambulance	01	0000000000000000000000001000000000000		2		1	175.00	175.00	2		2		2							
H8980	002	0	1	04	01	H8980_002_0	6	4	Home Health Group	01	0000010000000000000000000000000000000		2		2			2		2		2							
H8980	002	0	1	04	01	H8980_002_0	6	7	Preventive	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
H8980	004	0	1	04	01	H8980_004_0	4	7	30% Coinsurance OON	01	0000000000000000000000000111100000000		2		2			2		2		1		30		30			
H8980	004	0	1	04	01	H8980_004_0	4	8	30% Dental Coinsurance  (Non Medicare)	10		000000000000000000100000	1	1000.00	2			1	100.00	2		1		30		30			
H8980	004	0	1	04	01	H8980_004_0	4	6	Hearing Aid OON	10		000000000000000000000001	1	1000.00	2			2		2		1		50		50			
H8980	004	0	1	04	01	H8980_004_0	4	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	4	4	Ambulance OON	01	0000000000000000000000001000000000000		2		1	125.00	125.00	2		2		2							
H8980	004	0	1	04	01	H8980_004_0	4	3	0% Coinsurance OON	01	0000010000000000000000000000000000000		2		2			2		2		1		0		0			
H8980	004	0	1	04	01	H8980_004_0	4	2	45% Coinsurance OON	01	0000100000100100000000100000000000000		2		2			2		2		1		45		45			
H8980	004	0	1	04	01	H8980_004_0	4	12	OON services with sep office cost share	01	0000000000000000000000000000000100000		2		2			2		1	1	1	20	20	20	20	2		
H8980	004	0	1	04	01	H8980_004_0	4	11	$0 Copay OON	10		000000000000000000000100	1	150.00	1	0.00	0.00	2		2		2							
H8980	004	0	1	04	01	H8980_004_0	4	9	50% Dental Coinsurance	10		000000000000000000010000	2		2			1	100.00	2		1		50		50			
H8980	004	0	1	04	01	H8980_004_0	4	1	20% Coinsurance OON	11	0111001111011011111111010000011011111	000001100000000000001010	2		2			2		2		1		20		20			
H8980	004	0	1	04	01	H8980_004_0	4	10	Cost Sharing 0%-20%	01	0000000000000000000000000000010000000		2		2			2		2		1		0		20			
H8980	005	0	1	04	01	H8980_005_0	5	2	30% Coinsurance OON	01	0000000000000000000000001111100000000		2		2			2		2		1		30		30			
H8980	005	0	1	04	01	H8980_005_0	5	10	Separate Physician Cost Share OON	01	0000000000000000000000000000000100000		2		2			2		1	1	1	20	20	20	20	2		
H8980	005	0	1	04	01	H8980_005_0	5	1	20% Coinsurance OON	11	0111001111011011111111010000001111111	000001100000000000001010	2		2			2		2		1		20		20			
H8980	005	0	1	04	01	H8980_005_0	5	3	45% Coinsurance OON	01	0000100000100100000000100000000000000		2		2			2		2		1		45		45			
H8980	005	0	1	04	01	H8980_005_0	5	9	Preventive Services 0%-20%	01	0000000000000000000000000000010000000		2		2			2		2		1		0		20			
H8980	005	0	1	04	01	H8980_005_0	5	8	30% Dental Coinsurance (Non Medicare)	10		000000000000000000100000	1	1000.00	2			1	100.00	2		1		30		30			
H8980	005	0	1	04	01	H8980_005_0	5	7	50% Dental Coinsurance (Non Medicare)	10		000000000000000000010000	2		2			1	100.00	2		1		50		50			
H8980	005	0	1	04	01	H8980_005_0	5	6	$0 Copay OON	10		000000000000000000000100	1	150.00	1	0.00	0.00	2		2		2							
H8980	005	0	1	04	01	H8980_005_0	5	5	Gym OON - Monthly Copay	10		000000000000000010000000	2		1	50.00	50.00	2		2		2							
H8980	005	0	1	04	01	H8980_005_0	5	4	0% Coinsurance OON	01	0000010000000000000000000000000000000		2		2			2		2		1		0		0			
H8980	006	0	1	04	01	H8980_006_0	4	1	20% Coinsurance OON	11	0111001111011011111111010000001111111	000001100000000000001010	2		2			2		2		1		20		20			
H8980	006	0	1	04	01	H8980_006_0	4	10	Separate Physician Cost Share OON	01	0000000000000000000000000000000100000		2		2			2		1	1	1	20	20	20	20	2		
H8980	006	0	1	04	01	H8980_006_0	4	9	$0 Copay OON	10		000000000000000000000100	1	150.00	1	0.00	0.00	2		2		2							
H8980	006	0	1	04	01	H8980_006_0	4	8	50% Dental Coinsurance (Non Medicare)	10		000000000000000000010000	2		2			1	100.00	2		1		50		50			
H8980	006	0	1	04	01	H8980_006_0	4	7	30% Dental Coinsurance (Non Medicare)	10		000000000000000000100000	1	1000.00	2			1	100.00	2		1		30		30			
H8980	006	0	1	04	01	H8980_006_0	4	6	Preventive Services 0%-20%	01	0000000000000000000000000000010000000		2		2			2		2		1		0		20			
H8980	006	0	1	04	01	H8980_006_0	4	5	Gym OON - Monthly Copay	10		000000000000000010000000	2		1	50.00	50.00	2		2		2							
H8980	006	0	1	04	01	H8980_006_0	4	4	0% Coinsurance OON	01	0000010000000000000000000000000000000		2		2			2		2		1		0		0			
H8980	006	0	1	04	01	H8980_006_0	4	3	45% Coinsurance OON	01	0000100000100100000000100000000000000		2		2			2		2		1		45		45			
H8980	006	0	1	04	01	H8980_006_0	4	2	30% Coinsurance OON	01	0000000000000000000000001111100000000		2		2			2		2		1		30		30			
H8980	801	0	1	04	01	H8980_801_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H8980	801	0	1	04	01	H8980_801_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H8980	802	0	1	04	01	H8980_802_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H8980	802	0	1	04	01	H8980_802_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H8980	805	0	1	04	01	H8980_805_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H8980	805	0	1	04	01	H8980_805_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H8980	807	0	1	04	01	H8980_807_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H8980	807	0	1	04	01	H8980_807_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H9412	003	0	1	04	01	H9412_003_0	7	1	20% Coinsurance Benefits	11	0111110110100111100111110110000000010	000000000000000000100000	2		2			2		2		1		20		20			
H9412	003	0	1	04	01	H9412_003_0	7	10	Diabetic Supplies	01	0000000000000000000000000001000000000		2		2			2		2		1		0		25			
H9412	003	0	1	04	01	H9412_003_0	7	9	Diagnostic Radiology Services	01	0000000000000000010000000000000000000		2		2			2		2		1		20		35			
H9412	003	0	1	04	01	H9412_003_0	7	8	Hearing Aid and Hearing Aid Fitting	10		000000000000000000000001	1	1000.00	1	0.00	0.00	2		2		2							
H9412	003	0	1	04	01	H9412_003_0	7	7	Routine Eyewear	10		000000000000000000000100	1	200.00	1	0.00	0.00	2		2		2							
H9412	003	0	1	04	01	H9412_003_0	7	11	Eligible Supplemental Benefits	10		000000000000000010000000	1	90.00	2			2		2		2							
H9412	003	0	1	04	01	H9412_003_0	7	2	25% Coinsurance Benefits	01	0000000000000000000000000000100010000		2		2			2		2		1		25		25			
H9412	003	0	1	04	01	H9412_003_0	7	3	30% Coinsurance Benefit	01	0000000000000000001000000000000000000		2		2			2		2		1		30		30			
H9412	003	0	1	04	01	H9412_003_0	7	4	$30 Copayment Benefits	11	0000000001011000000000000000011101101	000001000000000000001010	2		1	30.00	30.00	2		2		2							
H9412	003	0	1	04	01	H9412_003_0	7	5	$15 Copayment Benefits	11	0000001000000000000000000000000000000	000000000000000100000000	2		1	15.00	15.00	2		2		2							
H9412	003	0	1	04	01	H9412_003_0	7	6	Ambulance	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H9412	801	0	1	04	01	H9412_801_0	6	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H9412	801	0	1	04	01	H9412_801_0	6	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H9412	802	0	1	04	01	H9412_802_0	6	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H9412	802	0	1	04	01	H9412_802_0	6	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H9572	001	1	1	04	01	H9572_001_1	11	4	Preventive Dental	10		000000000000000000100000	2		2			2		2		1		50		50			
H9572	001	1	1	04	01	H9572_001_1	11	3	Hearing exams	11	0000000000000000000000000000000000001	000000000000000000000010	2		2			2		2		1		50		50			
H9572	001	1	1	04	01	H9572_001_1	11	9	Supplemental Vision - Eyewear	10		000000000000000000000100	1	210.00	1	0.00	10.00	2		2		2							
H9572	001	1	1	04	01	H9572_001_1	11	8	Hearing aids	10		000000000000000000000001	1	1000.00	2			2		2		2							
H9572	001	1	1	04	01	H9572_001_1	11	7	Zero coinsurance/copay group	11	0000000000000000000000010001010100000	000000100000000000000000	2		2			2		2		2							
H9572	001	1	1	04	01	H9572_001_1	11	6	Supplemental Vision-eye exams	10		000000000000000000001000	2		1	0.00	10.00	2		2		2							
H9572	001	1	1	04	01	H9572_001_1	11	5	Medicare Part B drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		40		40			
H9572	001	1	1	04	01	H9572_001_1	11	1	Global coinsurance group	11	0111111111111111111111101000101001110	000010000000100110000000	2		2			2		2		1		40		40			
H9572	001	1	1	04	01	H9572_001_1	11	10	Total Body Skin Exam	10		000000000001000000000000	2		2			2		2		1		40		40			
H9572	001	1	1	04	01	H9572_001_1	11	2	DME & Prosthetics	01	0000000000000000000000000110000000000		2		2			2		2		1		40		40			
H9572	001	2	1	04	01	H9572_001_2	11	6	Supplemental Vision-eye exams	10		000000000000000000001000	2		1	0.00	10.00	2		2		2							
H9572	001	2	1	04	01	H9572_001_2	11	9	Supplemental Vision - Eyewear	10		000000000000000000000100	1	210.00	1	0.00	10.00	2		2		2							
H9572	001	2	1	04	01	H9572_001_2	11	8	Hearing aids	10		000000000000000000000001	1	1000.00	2			2		2		2							
H9572	001	2	1	04	01	H9572_001_2	11	4	Preventive Dental	10		000000000000000000100000	2		2			2		2		1		50		50			
H9572	001	2	1	04	01	H9572_001_2	11	1	Global coinsurance group	11	0111111111111111111111101000101001110	000010000000100110000000	2		2			2		2		1		40		40			
H9572	001	2	1	04	01	H9572_001_2	11	2	DME & Prosthetics	01	0000000000000000000000000110000000000		2		2			2		2		1		40		40			
H9572	001	2	1	04	01	H9572_001_2	11	10	Total Body Skin Exam	10		000000000001000000000000	2		2			2		2		1		40		40			
H9572	001	2	1	04	01	H9572_001_2	11	5	Medicare Part B drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		40		40			
H9572	001	2	1	04	01	H9572_001_2	11	7	Zero coinsurance/copay group	11	0000000000000000000000010001010100000	000000100000000000000000	2		2			2		2		2							
H9572	001	2	1	04	01	H9572_001_2	11	3	Hearing exams	11	0000000000000000000000000000000000001	000000000000000000000010	2		2			2		2		1		50		50			
H9572	001	3	1	04	01	H9572_001_3	11	7	Zero coinsurance/copay group	11	0000000000000000000000010001010100000	000000100000000000000000	2		2			2		2		2							
H9572	001	3	1	04	01	H9572_001_3	11	8	Hearing aids	10		000000000000000000000001	1	1000.00	2			2		2		2							
H9572	001	3	1	04	01	H9572_001_3	11	9	Supplemental Vision - Eyewear	10		000000000000000000000100	1	210.00	1	0.00	10.00	2		2		2							
H9572	001	3	1	04	01	H9572_001_3	11	6	Supplemental Vision-eye exams	10		000000000000000000001000	2		1	0.00	10.00	2		2		2							
H9572	001	3	1	04	01	H9572_001_3	11	4	Preventive Dental	10		000000000000000000100000	2		2			2		2		1		50		50			
H9572	001	3	1	04	01	H9572_001_3	11	3	Hearing exams	11	0000000000000000000000000000000000001	000000000000000000000010	2		2			2		2		1		50		50			
H9572	001	3	1	04	01	H9572_001_3	11	2	DME & Prosthetics	01	0000000000000000000000000110000000000		2		2			2		2		1		40		40			
H9572	001	3	1	04	01	H9572_001_3	11	10	Total Body Skin Exam	10		000000000001000000000000	2		2			2		2		1		40		40			
H9572	001	3	1	04	01	H9572_001_3	11	1	Global coinsurance group	11	0111111111111111111111101000101001110	000010000000100110000000	2		2			2		2		1		40		40			
H9572	001	3	1	04	01	H9572_001_3	11	5	Medicare Part B drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		40		40			
H9572	001	4	1	04	01	H9572_001_4	11	9	Supplemental Vision - Eyewear	10		000000000000000000000100	1	210.00	1	0.00	10.00	2		2		2							
H9572	001	4	1	04	01	H9572_001_4	11	8	Hearing aids	10		000000000000000000000001	1	1000.00	2			2		2		2							
H9572	001	4	1	04	01	H9572_001_4	11	7	Zero coinsurance/copay group	11	0000000000000000000000010001010100000	000000100000000000000000	2		2			2		2		2							
H9572	001	4	1	04	01	H9572_001_4	11	6	Supplemental Vision-eye exams	10		000000000000000000001000	2		1	0.00	10.00	2		2		2							
H9572	001	4	1	04	01	H9572_001_4	11	5	Medicare Part B drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		40		40			
H9572	001	4	1	04	01	H9572_001_4	11	4	Preventive Dental	10		000000000000000000100000	2		2			2		2		1		50		50			
H9572	001	4	1	04	01	H9572_001_4	11	3	Hearing exams	11	0000000000000000000000000000000000001	000000000000000000000010	2		2			2		2		1		50		50			
H9572	001	4	1	04	01	H9572_001_4	11	2	DME & Prosthetics	01	0000000000000000000000000110000000000		2		2			2		2		1		40		40			
H9572	001	4	1	04	01	H9572_001_4	11	10	Total Body Skin Exam	10		000000000001000000000000	2		2			2		2		1		40		40			
H9572	001	4	1	04	01	H9572_001_4	11	1	Global coinsurance group	11	0111111111111111111111101000101001110	000010000000100110000000	2		2			2		2		1		40		40			
H9572	001	6	1	04	01	H9572_001_6	11	1	Global coinsurance group	11	0111111111111111111111101000101001110	000010000000100110000000	2		2			2		2		1		40		40			
H9572	001	6	1	04	01	H9572_001_6	11	10	Total Body Skin Exam	10		000000000001000000000000	2		2			2		2		1		40		40			
H9572	001	6	1	04	01	H9572_001_6	11	2	DME & Prosthetics	01	0000000000000000000000000110000000000		2		2			2		2		1		40		40			
H9572	001	6	1	04	01	H9572_001_6	11	3	Hearing exams	11	0000000000000000000000000000000000001	000000000000000000000010	2		2			2		2		1		50		50			
H9572	001	6	1	04	01	H9572_001_6	11	9	Supplemental Vision - Eyewear	10		000000000000000000000100	1	210.00	1	0.00	10.00	2		2		2							
H9572	001	6	1	04	01	H9572_001_6	11	5	Medicare Part B drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		40		40			
H9572	001	6	1	04	01	H9572_001_6	11	6	Supplemental Vision-eye exams	10		000000000000000000001000	2		1	0.00	10.00	2		2		2							
H9572	001	6	1	04	01	H9572_001_6	11	7	Zero coinsurance/copay group	11	0000000000000000000000010001010100000	000000100000000000000000	2		2			2		2		2							
H9572	001	6	1	04	01	H9572_001_6	11	8	Hearing aids	10		000000000000000000000001	1	1000.00	2			2		2		2							
H9572	001	6	1	04	01	H9572_001_6	11	4	Preventive Dental	10		000000000000000000100000	2		2			2		2		1		50		50			
H9572	002	1	1	04	01	H9572_002_1	12	5	Medicare Part B drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		40		40			
H9572	002	1	1	04	01	H9572_002_1	12	6	Supplemental Vision-eye exams	10		000000000000000000001000	2		1	0.00	10.00	2		2		2							
H9572	002	1	1	04	01	H9572_002_1	12	7	Zero coinsurance/copay group	11	0000000000000000000000010001010100000	000000100000000000000000	2		2			2		2		2							
H9572	002	1	1	04	01	H9572_002_1	12	8	Hearing aids	10		000000000000000000000001	1	1000.00	2			2		2		2							
H9572	002	1	1	04	01	H9572_002_1	12	9	Supplemental Vision - Eyewear	10		000000000000000000000100	1	210.00	1	0.00	10.00	2		2		2							
H9572	002	1	1	04	01	H9572_002_1	12	1	Global coinsurance group	11	0111111111111111111111101000101001110	000010000000100110000000	2		2			2		2		1		40		40			
H9572	002	1	1	04	01	H9572_002_1	12	10	Total Body Skin exam	10		000000000001000000000000	2		2			2		2		1		40		40			
H9572	002	1	1	04	01	H9572_002_1	12	2	DME & Prosthetics	01	0000000000000000000000000110000000000		2		2			2		2		1		40		40			
H9572	002	1	1	04	01	H9572_002_1	12	3	Hearing exams	11	0000000000000000000000000000000000001	000000000000000000000010	2		2			2		2		1		50		50			
H9572	002	1	1	04	01	H9572_002_1	12	4	Preventive Dental	10		000000000000000000100000	2		2			2		2		1		50		50			
H9572	002	2	1	04	01	H9572_002_2	11	1	Global coinsurance group	11	0111111111111111111111101000101001110	000010000000100110000000	2		2			2		2		1		40		40			
H9572	002	2	1	04	01	H9572_002_2	11	10	Total Body Skin exam	10		000000000001000000000000	2		2			2		2		1		40		40			
H9572	002	2	1	04	01	H9572_002_2	11	2	DME & Prosthetics	01	0000000000000000000000000110000000000		2		2			2		2		1		40		40			
H9572	002	2	1	04	01	H9572_002_2	11	3	Hearing exams	11	0000000000000000000000000000000000001	000000000000000000000010	2		2			2		2		1		50		50			
H9572	002	2	1	04	01	H9572_002_2	11	9	Supplemental Vision - Eyewear	10		000000000000000000000100	1	210.00	1	0.00	10.00	2		2		2							
H9572	002	2	1	04	01	H9572_002_2	11	5	Medicare Part B drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		40		40			
H9572	002	2	1	04	01	H9572_002_2	11	6	Supplemental Vision-eye exams	10		000000000000000000001000	2		1	0.00	10.00	2		2		2							
H9572	002	2	1	04	01	H9572_002_2	11	7	Zero coinsurance/copay group	11	0000000000000000000000010001010100000	000000100000000000000000	2		2			2		2		2							
H9572	002	2	1	04	01	H9572_002_2	11	8	Hearing aids	10		000000000000000000000001	1	1000.00	2			2		2		2							
H9572	002	2	1	04	01	H9572_002_2	11	4	Preventive Dental	10		000000000000000000100000	2		2			2		2		1		50		50			
H9572	002	3	1	04	01	H9572_002_3	11	1	Global coinsurance group	11	0111111111111111111111101000101001110	000010000000100110000000	2		2			2		2		1		40		40			
H9572	002	3	1	04	01	H9572_002_3	11	10	Total Body Skin exam	10		000000000001000000000000	2		2			2		2		1		40		40			
H9572	002	3	1	04	01	H9572_002_3	11	2	DME & Prosthetics	01	0000000000000000000000000110000000000		2		2			2		2		1		40		40			
H9572	002	3	1	04	01	H9572_002_3	11	3	Hearing exams	11	0000000000000000000000000000000000001	000000000000000000000010	2		2			2		2		1		50		50			
H9572	002	3	1	04	01	H9572_002_3	11	4	Preventive Dental	10		000000000000000000100000	2		2			2		2		1		50		50			
H9572	002	3	1	04	01	H9572_002_3	11	5	Medicare Part B drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		40		40			
H9572	002	3	1	04	01	H9572_002_3	11	6	Supplemental Vision-eye exams	10		000000000000000000001000	2		1	0.00	10.00	2		2		2							
H9572	002	3	1	04	01	H9572_002_3	11	7	Zero coinsurance/copay group	11	0000000000000000000000010001010100000	000000100000000000000000	2		2			2		2		2							
H9572	002	3	1	04	01	H9572_002_3	11	8	Hearing aids	10		000000000000000000000001	1	1000.00	2			2		2		2							
H9572	002	3	1	04	01	H9572_002_3	11	9	Supplemental Vision - Eyewear	10		000000000000000000000100	1	210.00	1	0.00	10.00	2		2		2							
H9572	002	4	1	04	01	H9572_002_4	11	1	Global coinsurance group	11	0111111111111111111111101000101001110	000010000000100110000000	2		2			2		2		1		40		40			
H9572	002	4	1	04	01	H9572_002_4	11	10	Total Body Skin exam	10		000000000001000000000000	2		2			2		2		1		40		40			
H9572	002	4	1	04	01	H9572_002_4	11	9	Supplemental Vision - Eyewear	10		000000000000000000000100	1	210.00	1	0.00	10.00	2		2		2							
H9572	002	4	1	04	01	H9572_002_4	11	8	Hearing aids	10		000000000000000000000001	1	1000.00	2			2		2		2							
H9572	002	4	1	04	01	H9572_002_4	11	7	Zero coinsurance/copay group	11	0000000000000000000000010001010100000	000000100000000000000000	2		2			2		2		2							
H9572	002	4	1	04	01	H9572_002_4	11	6	Supplemental Vision-eye exams	10		000000000000000000001000	2		1	0.00	10.00	2		2		2							
H9572	002	4	1	04	01	H9572_002_4	11	5	Medicare Part B drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		40		40			
H9572	002	4	1	04	01	H9572_002_4	11	4	Preventive Dental	10		000000000000000000100000	2		2			2		2		1		50		50			
H9572	002	4	1	04	01	H9572_002_4	11	3	Hearing exams	11	0000000000000000000000000000000000001	000000000000000000000010	2		2			2		2		1		50		50			
H9572	002	4	1	04	01	H9572_002_4	11	2	DME & Prosthetics	01	0000000000000000000000000110000000000		2		2			2		2		1		40		40			
H9572	002	6	1	04	01	H9572_002_6	11	1	Global coinsurance group	11	0111111111111111111111101000101001110	000010000000100110000000	2		2			2		2		1		40		40			
H9572	002	6	1	04	01	H9572_002_6	11	8	Hearing aids	10		000000000000000000000001	1	1000.00	2			2		2		2							
H9572	002	6	1	04	01	H9572_002_6	11	7	Zero coinsurance/copay group	11	0000000000000000000000010001010100000	000000100000000000000000	2		2			2		2		2							
H9572	002	6	1	04	01	H9572_002_6	11	6	Supplemental Vision-eye exams	10		000000000000000000001000	2		1	0.00	10.00	2		2		2							
H9572	002	6	1	04	01	H9572_002_6	11	9	Supplemental Vision - Eyewear	10		000000000000000000000100	1	210.00	1	0.00	10.00	2		2		2							
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 exams	11	0000000000000000000000000000000000001	000000000000000000000010	2		2			2		2		1		50		50			
H9572	002	6	1	04	01	H9572_002_6	11	2	DME & Prosthetics	01	0000000000000000000000000110000000000		2		2			2		2		1		40		40			
H9572	002	6	1	04	01	H9572_002_6	11	10	Total Body Skin exam	10		000000000001000000000000	2		2			2		2		1		40		40			
H9572	002	6	1	04	01	H9572_002_6	11	5	Medicare Part B drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		40		40			
H9572	003	1	1	04	01	H9572_003_1	11	4	Preventive Dental	10		000000000000000000100000	2		2			2		2		1		50		50			
H9572	003	1	1	04	01	H9572_003_1	11	5	Medicare Part B drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		30		30			
H9572	003	1	1	04	01	H9572_003_1	11	3	Hearing exams	11	0000000000000000000000000000000000001	000000000000000000000010	2		2			2		2		1		50		50			
H9572	003	1	1	04	01	H9572_003_1	11	2	DME & Prosthetics	01	0000000000000000000000000110000000000		2		2			2		2		1		30		30			
H9572	003	1	1	04	01	H9572_003_1	11	10	Total Body Skin exam	10		000000000001000000000000	2		2			2		2		1		30		30			
H9572	003	1	1	04	01	H9572_003_1	11	1	Global coinsurance group	11	0111111111111111111111101000101001110	000010000000100110000000	2		2			2		2		1		30		30			
H9572	003	1	1	04	01	H9572_003_1	11	9	Supplemental Vision - Eyewear	10		000000000000000000000100	1	210.00	1	0.00	10.00	2		2		2							
H9572	003	1	1	04	01	H9572_003_1	11	8	Hearing aids	10		000000000000000000000001	1	1000.00	2			2		2		2							
H9572	003	1	1	04	01	H9572_003_1	11	7	Zero coinsurance/copay group	11	0000000000000000000000010001010100000	000000100000000000000000	2		2			2		2		2							
H9572	003	1	1	04	01	H9572_003_1	11	6	Supplemental Vision-eye exams	10		000000000000000000001000	2		1	0.00	10.00	2		2		2							
H9572	003	2	1	04	01	H9572_003_2	11	6	Supplemental Vision-eye exams	10		000000000000000000001000	2		1	0.00	10.00	2		2		2							
H9572	003	2	1	04	01	H9572_003_2	11	5	Medicare Part B drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		30		30			
H9572	003	2	1	04	01	H9572_003_2	11	4	Preventive Dental	10		000000000000000000100000	2		2			2		2		1		50		50			
H9572	003	2	1	04	01	H9572_003_2	11	9	Supplemental Vision - Eyewear	10		000000000000000000000100	1	210.00	1	0.00	10.00	2		2		2							
H9572	003	2	1	04	01	H9572_003_2	11	7	Zero coinsurance/copay group	11	0000000000000000000000010001010100000	000000100000000000000000	2		2			2		2		2							
H9572	003	2	1	04	01	H9572_003_2	11	2	DME & Prosthetics	01	0000000000000000000000000110000000000		2		2			2		2		1		30		30			
H9572	003	2	1	04	01	H9572_003_2	11	10	Total Body Skin exam	10		000000000001000000000000	2		2			2		2		1		30		30			
H9572	003	2	1	04	01	H9572_003_2	11	1	Global coinsurance group	11	0111111111111111111111101000101001110	000010000000100110000000	2		2			2		2		1		30		30			
H9572	003	2	1	04	01	H9572_003_2	11	8	Hearing aids	10		000000000000000000000001	1	1000.00	2			2		2		2							
H9572	003	2	1	04	01	H9572_003_2	11	3	Hearing exams	11	0000000000000000000000000000000000001	000000000000000000000010	2		2			2		2		1		50		50			
H9572	003	3	1	04	01	H9572_003_3	11	8	Hearing aids	10		000000000000000000000001	1	1000.00	2			2		2		2							
H9572	003	3	1	04	01	H9572_003_3	11	7	Zero coinsurance/copay group	11	0000000000000000000000010001010100000	000000100000000000000000	2		2			2		2		2							
H9572	003	3	1	04	01	H9572_003_3	11	6	Supplemental Vision-eye exams	10		000000000000000000001000	2		1	0.00	10.00	2		2		2							
H9572	003	3	1	04	01	H9572_003_3	11	5	Medicare Part B drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		30		30			
H9572	003	3	1	04	01	H9572_003_3	11	4	Preventive Dental	10		000000000000000000100000	2		2			2		2		1		50		50			
H9572	003	3	1	04	01	H9572_003_3	11	3	Hearing exams	11	0000000000000000000000000000000000001	000000000000000000000010	2		2			2		2		1		50		50			
H9572	003	3	1	04	01	H9572_003_3	11	2	DME & Prosthetics	01	0000000000000000000000000110000000000		2		2			2		2		1		30		30			
H9572	003	3	1	04	01	H9572_003_3	11	10	Total Body Skin exam	10		000000000001000000000000	2		2			2		2		1		30		30			
H9572	003	3	1	04	01	H9572_003_3	11	1	Global coinsurance group	11	0111111111111111111111101000101001110	000010000000100110000000	2		2			2		2		1		30		30			
H9572	003	3	1	04	01	H9572_003_3	11	9	Supplemental Vision - Eyewear	10		000000000000000000000100	1	210.00	1	0.00	10.00	2		2		2							
H9572	003	4	1	04	01	H9572_003_4	11	1	Global coinsurance group	11	0111111111111111111111101000101001110	000010000000100110000000	2		2			2		2		1		30		30			
H9572	003	4	1	04	01	H9572_003_4	11	10	Total Body Skin exam	10		000000000001000000000000	2		2			2		2		1		30		30			
H9572	003	4	1	04	01	H9572_003_4	11	9	Supplemental Vision - Eyewear	10		000000000000000000000100	1	210.00	1	0.00	10.00	2		2		2							
H9572	003	4	1	04	01	H9572_003_4	11	8	Hearing aids	10		000000000000000000000001	1	1000.00	2			2		2		2							
H9572	003	4	1	04	01	H9572_003_4	11	7	Zero coinsurance/copay group	11	0000000000000000000000010001010100000	000000100000000000000000	2		2			2		2		2							
H9572	003	4	1	04	01	H9572_003_4	11	6	Supplemental Vision-eye exams	10		000000000000000000001000	2		1	0.00	10.00	2		2		2							
H9572	003	4	1	04	01	H9572_003_4	11	5	Medicare Part B drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		30		30			
H9572	003	4	1	04	01	H9572_003_4	11	4	Preventive Dental	10		000000000000000000100000	2		2			2		2		1		50		50			
H9572	003	4	1	04	01	H9572_003_4	11	3	Hearing exams	11	0000000000000000000000000000000000001	000000000000000000000010	2		2			2		2		1		50		50			
H9572	003	4	1	04	01	H9572_003_4	11	2	DME & Prosthetics	01	0000000000000000000000000110000000000		2		2			2		2		1		30		30			
H9572	003	6	1	04	01	H9572_003_6	11	1	Global coinsurance group	11	0111111111111111111111101000101001110	000010000000100110000000	2		2			2		2		1		30		30			
H9572	003	6	1	04	01	H9572_003_6	11	10	Total Body Skin exam	10		000000000001000000000000	2		2			2		2		1		30		30			
H9572	003	6	1	04	01	H9572_003_6	11	2	DME & Prosthetics	01	0000000000000000000000000110000000000		2		2			2		2		1		30		30			
H9572	003	6	1	04	01	H9572_003_6	11	3	Hearing exams	11	0000000000000000000000000000000000001	000000000000000000000010	2		2			2		2		1		50		50			
H9572	003	6	1	04	01	H9572_003_6	11	9	Supplemental Vision - Eyewear	10		000000000000000000000100	1	210.00	1	0.00	10.00	2		2		2							
H9572	003	6	1	04	01	H9572_003_6	11	5	Medicare Part B drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		30		30			
H9572	003	6	1	04	01	H9572_003_6	11	6	Supplemental Vision-eye exams	10		000000000000000000001000	2		1	0.00	10.00	2		2		2							
H9572	003	6	1	04	01	H9572_003_6	11	7	Zero coinsurance/copay group	11	0000000000000000000000010001010100000	000000100000000000000000	2		2			2		2		2							
H9572	003	6	1	04	01	H9572_003_6	11	8	Hearing aids	10		000000000000000000000001	1	1000.00	2			2		2		2							
H9572	003	6	1	04	01	H9572_003_6	11	4	Preventive Dental	10		000000000000000000100000	2		2			2		2		1		50		50			
H9572	004	1	1	04	01	H9572_004_1	11	1	Global coinsurance group	11	0111111111111111111111101000101001110	000010000000100110000000	2		2			2		2		1		40		40			
H9572	004	1	1	04	01	H9572_004_1	11	2	DME & Prosthetics	01	0000000000000000000000000110000000000		2		2			2		2		1		40		40			
H9572	004	1	1	04	01	H9572_004_1	11	3	Hearing exams	01	0000000000000000000000000000000000001		2		2			2		2		1		50		50			
H9572	004	1	1	04	01	H9572_004_1	11	4	Zero coinsurance/copay group	11	0000000000000000000000010001010100000	000000100000000000000000	2		2			2		2		2							
H9572	004	1	1	04	01	H9572_004_1	11	5	Medicare Part B drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		40		40			
H9572	004	1	1	04	01	H9572_004_1	11	6	Total Body Skin exam	10		000000000001000000000000	2		2			2		2		1		40		40			
H9572	004	2	1	04	01	H9572_004_2	11	1	Global coinsurance group	11	0111111111111111111111101000101001110	000010000000100110000000	2		2			2		2		1		40		40			
H9572	004	2	1	04	01	H9572_004_2	11	2	DME & Prosthetics	01	0000000000000000000000000110000000000		2		2			2		2		1		40		40			
H9572	004	2	1	04	01	H9572_004_2	11	3	Hearing exams	01	0000000000000000000000000000000000001		2		2			2		2		1		50		50			
H9572	004	2	1	04	01	H9572_004_2	11	4	Zero coinsurance/copay group	11	0000000000000000000000010001010100000	000000100000000000000000	2		2			2		2		2							
H9572	004	2	1	04	01	H9572_004_2	11	5	Medicare Part B drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		40		40			
H9572	004	2	1	04	01	H9572_004_2	11	6	Total Body Skin exam	10		000000000001000000000000	2		2			2		2		1		40		40			
H9572	004	3	1	04	01	H9572_004_3	11	4	Zero coinsurance/copay group	11	0000000000000000000000010001010100000	000000100000000000000000	2		2			2		2		2							
H9572	004	3	1	04	01	H9572_004_3	11	5	Medicare Part B drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		40		40			
H9572	004	3	1	04	01	H9572_004_3	11	6	Total Body Skin exam	10		000000000001000000000000	2		2			2		2		1		40		40			
H9572	004	3	1	04	01	H9572_004_3	11	1	Global coinsurance group	11	0111111111111111111111101000101001110	000010000000100110000000	2		2			2		2		1		40		40			
H9572	004	3	1	04	01	H9572_004_3	11	2	DME & Prosthetics	01	0000000000000000000000000110000000000		2		2			2		2		1		40		40			
H9572	004	3	1	04	01	H9572_004_3	11	3	Hearing exams	01	0000000000000000000000000000000000001		2		2			2		2		1		50		50			
H9572	004	4	1	04	01	H9572_004_4	11	3	Hearing exams	01	0000000000000000000000000000000000001		2		2			2		2		1		50		50			
H9572	004	4	1	04	01	H9572_004_4	11	2	DME & Prosthetics	01	0000000000000000000000000110000000000		2		2			2		2		1		40		40			
H9572	004	4	1	04	01	H9572_004_4	11	1	Global coinsurance group	11	0111111111111111111111101000101001110	000010000000100110000000	2		2			2		2		1		40		40			
H9572	004	4	1	04	01	H9572_004_4	11	4	Zero coinsurance/copay group	11	0000000000000000000000010001010100000	000000100000000000000000	2		2			2		2		2							
H9572	004	4	1	04	01	H9572_004_4	11	5	Medicare Part B drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		40		40			
H9572	004	4	1	04	01	H9572_004_4	11	6	Total Body Skin exam	10		000000000001000000000000	2		2			2		2		1		40		40			
H9572	004	6	1	04	01	H9572_004_6	12	3	Hearing exams	01	0000000000000000000000000000000000001		2		2			2		2		1		50		50			
H9572	004	6	1	04	01	H9572_004_6	12	2	DME & Prosthetics	01	0000000000000000000000000110000000000		2		2			2		2		1		40		40			
H9572	004	6	1	04	01	H9572_004_6	12	1	Global coinsurance group	11	0111111111111111111111101000101001110	000010000000100110000000	2		2			2		2		1		40		40			
H9572	004	6	1	04	01	H9572_004_6	12	4	Zero coinsurance/copay group	11	0000000000000000000000010001010100000	000000100000000000000000	2		2			2		2		2							
H9572	004	6	1	04	01	H9572_004_6	12	6	Total Body Skin exam	10		000000000001000000000000	2		2			2		2		1		40		40			
H9572	004	6	1	04	01	H9572_004_6	12	5	Medicare Part B drugs	01	0000000000000000000000000000000010000		2		2			2		2		1		40		40			
H9572	801	0	1	04	01	H9572_801_0	9	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H9572	801	0	1	04	01	H9572_801_0	9	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H9572	802	0	1	04	01	H9572_802_0	9	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H9572	802	0	1	04	01	H9572_802_0	9	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H9572	803	0	1	04	01	H9572_803_0	8	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H9572	803	0	1	04	01	H9572_803_0	8	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H9572	804	0	1	04	01	H9572_804_0	8	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H9572	804	0	1	04	01	H9572_804_0	8	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H9615	007	0	1	04	01	H9615_007_0	7	1	40%	01	0000010000000001111011000111000010010		2		2			2		2		1		40		40			
H9615	007	0	1	04	01	H9615_007_0	7	5	$125 Copay	01	0000000000000000000000001000000000000		2		1	125.00	125.00	2		2		2							
H9615	007	0	1	04	01	H9615_007_0	7	4	$0	11	0000000000000000000000010000111100000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H9615	007	0	1	04	01	H9615_007_0	7	3	$20	01	0000000100000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H9615	007	0	1	04	01	H9615_007_0	7	6	50% Coinsurance	10		000000001000000000000000	2		2			2		2		1		50		50			
H9615	007	0	1	04	01	H9615_007_0	7	2	$60 Copay	11	0111101011111110000100100000000001101	000000000000000000001000	2		1	60.00	60.00	2		2		2							
H9615	008	0	1	04	01	H9615_008_0	6	4	$0	11	0000000000000000000000010000111100000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H9615	008	0	1	04	01	H9615_008_0	6	3	$20	01	0000000100000000000000000000000000000		2		1	20.00	20.00	2		2		2							
H9615	008	0	1	04	01	H9615_008_0	6	2	$60 Copay	11	0111101011111110000100100000000001101	000000000000000000001000	2		1	60.00	60.00	2		2		2							
H9615	008	0	1	04	01	H9615_008_0	6	1	40%	01	0000010000000001111011000111000010010		2		2			2		2		1		40		40			
H9615	008	0	1	04	01	H9615_008_0	6	5	$200 Copay	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H9615	802	0	1	04	01	H9615_802_0	5	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H9615	802	0	1	04	01	H9615_802_0	5	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H9615	807	0	1	04	01	H9615_807_0	3	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H9615	807	0	1	04	01	H9615_807_0	3	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H9615	810	0	1	04	01	H9615_810_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H9615	810	0	1	04	01	H9615_810_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H9615	811	0	1	04	01	H9615_811_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H9615	811	0	1	04	01	H9615_811_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H9847	001	0	1	04	01	H9847_001_0	7	1	$35 COPAY	01	0000001000000000000000000000000000000		2		1	35.00	35.00	2		2		2							
H9847	001	0	1	04	01	H9847_001_0	7	10	ZERO COPAY	11	0000000000000000000000000000011000010	000000000000000000001000	2		2			2		2		2							
H9847	001	0	1	04	01	H9847_001_0	7	11	20% costshare	01	0000000000000000000000000001000000000		2		2			2		2		1		20		20			
H9847	001	0	1	04	01	H9847_001_0	7	12	$75.00 ALLOWANCE	10		000000000000000000000100	1	75.00	2			2		2		2							
H9847	001	0	1	04	01	H9847_001_0	7	13	Zero copay	01	0000000000000000000000000000000100000		2		2			2		1	2	2					1	0.00	55.00
H9847	001	0	1	04	01	H9847_001_0	7	2	$45 COPAY	01	0000000000000000000000000000000001001		2		1	45.00	45.00	2		2		2							
H9847	001	0	1	04	01	H9847_001_0	7	9	ALLOWANCE $90.00	10		000000000000000000100000	1	90.00	2			2		2		2							
H9847	001	0	1	04	01	H9847_001_0	7	4	FITNESS	10		000000000000000010000000	2		1	0.00	50.00	2		2		2							
H9847	001	0	1	04	01	H9847_001_0	7	5	30%	01	0000000000000000001000000110000000000		2		2			2		2		1		30		30			
H9847	001	0	1	04	01	H9847_001_0	7	6	$200	01	0000000000000000000000001000000000000		2		1	200.00	200.00	2		2		2							
H9847	001	0	1	04	01	H9847_001_0	7	7	25%	01	0000000000000001110100000000000000000		2		2			2		1	2	1		25		25	1	45.00	45.00
H9847	001	0	1	04	01	H9847_001_0	7	8	20%	11	0111110100000000000011110000100010000	000000100000000000000000	2		2			2		2		1		20		20			
H9847	001	0	1	04	01	H9847_001_0	7	3	$55.00 COPAY	01	0000000011111110000000000000000000100		2		1	55.00	55.00	2		2		2							
H9847	005	0	1	04	01	H9847_005_0	9	1	Coins. 30%	11	0000110000000000000011111111100010000	000000100000000000000000	2		2			2		2		1		30		30			
H9847	005	0	1	04	01	H9847_005_0	9	2	Zero costshare	01	0000000000000000000000000000011000010		2		1	0.00	0.00	2		2		2							
H9847	005	0	1	04	01	H9847_005_0	9	9	Zero copay	01	0000000000000000000000000000000100000		2		2			2		1	2	2					1	0.00	49.00
H9847	005	0	1	04	01	H9847_005_0	9	8	30%	01	0000000000000001111100000000000000000		2		2			2		1	2	1		30		30	1	40.00	49.00
H9847	005	0	1	04	01	H9847_005_0	9	7	$100 Allowance	10		000000000000000000100000	1	100.00	2			2		2		2							
H9847	005	0	1	04	01	H9847_005_0	9	6	$90.00 Allowance	10		000000000000000000000100	1	90.00	2			2		2		2							
H9847	005	0	1	04	01	H9847_005_0	9	5	$49 Costshare	11	0111000111111110000000000000000001101	000000000000000000001000	2		1	49.00	49.00	2		2		2							
H9847	005	0	1	04	01	H9847_005_0	9	4	$40.00 Costshare	01	0000001000000000000000000000000000000		2		1	40.00	40.00	2		2		2							
H9847	005	0	1	04	01	H9847_005_0	9	3	$50 costshare Fitness facility	10		000000000000000010000000	2		1	0.00	50.00	2		2		2							
H9847	801	0	1	04	01	H9847_801_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H9847	801	0	1	04	01	H9847_801_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H9847	802	0	1	04	01	H9847_802_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H9847	802	0	1	04	01	H9847_802_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H9847	804	0	1	04	01	H9847_804_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H9847	804	0	1	04	01	H9847_804_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H9847	805	0	1	04	01	H9847_805_0	1	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H9847	805	0	1	04	01	H9847_805_0	1	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H9947	005	1	1	04	01	H9947_005_1	13	11	20%	11	0000000000000000000000000000100000000	000000000000000000100000	2		2			2		2		1		20		20			
H9947	005	1	1	04	01	H9947_005_1	13	9	Labs	01	0000000000000000100000000000000000000		2		1	40.00	40.00	2		1	2	2					1	30.00	45.00
H9947	005	1	1	04	01	H9947_005_1	13	1	$0	11	0000010000000000000000010000001101010	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H9947	005	1	1	04	01	H9947_005_1	13	12	Preventive	01	0000000000000000000000000000010000000		2		1	0.00	45.00	2		2		2							
H9947	005	1	1	04	01	H9947_005_1	13	13	Diag	01	0000000000000000010000000000000000000		2		1	150.00	170.00	2		2		2							
H9947	005	1	1	04	01	H9947_005_1	13	14	Eye	10		000000000000000000001000	1	69.00	1	0.00	0.00	2		2		2							
H9947	005	1	1	04	01	H9947_005_1	13	15	25%	01	0000000000000000000001000000000000000		2		2			2		2		1		25		25			
H9947	005	1	1	04	01	H9947_005_1	13	2	Therapeutic	01	0000000000000000001000000000000000000		2		2			2		1	2	1		25		25	1	30.00	45.00
H9947	005	1	1	04	01	H9947_005_1	13	3	Outpatient	01	0000000000000000000010000000000000000		2		1	30.00	45.00	2		2		1		25		25			
H9947	005	1	1	04	01	H9947_005_1	13	4	PCP	01	0000001000001000000000000000000000000		2		1	30.00	30.00	2		2		2							
H9947	005	1	1	04	01	H9947_005_1	13	5	$80	01	0000100000100100000000100000000000000		2		1	80.00	80.00	2		2		2							
H9947	005	1	1	04	01	H9947_005_1	13	6	DME/ASC	01	0000000000000000000000000111000010000		2		2			2		2		1		30		30			
H9947	005	1	1	04	01	H9947_005_1	13	7	$45	11	0111000111010010000000000000000000101	000000000000000100000000	2		1	45.00	45.00	2		2		2							
H9947	005	1	1	04	01	H9947_005_1	13	8	Radiology	01	0000000000000001000100000000000000000		2		1	110.00	170.00	2		1	2	2					1	30.00	45.00
H9947	005	1	1	04	01	H9947_005_1	13	10	Ambulance	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H9947	005	2	1	04	01	H9947_005_2	13	11	20%	11	0000000000000000000000000000100000000	000000000000000000100000	2		2			2		2		1		20		20			
H9947	005	2	1	04	01	H9947_005_2	13	10	Ambulance	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
H9947	005	2	1	04	01	H9947_005_2	13	1	$0	11	0000010000000000000000010000001101010	000000100000000010000000	2		1	0.00	0.00	2		2		2							
H9947	005	2	1	04	01	H9947_005_2	13	12	Preventive	01	0000000000000000000000000000010000000		2		1	0.00	45.00	2		2		2							
H9947	005	2	1	04	01	H9947_005_2	13	9	Labs	01	0000000000000000100000000000000000000		2		1	40.00	40.00	2		1	2	2					1	30.00	45.00
H9947	005	2	1	04	01	H9947_005_2	13	8	Radiology	01	0000000000000001000100000000000000000		2		1	110.00	170.00	2		1	2	2					1	30.00	45.00
H9947	005	2	1	04	01	H9947_005_2	13	7	$45	11	0111000111010010000000000000000000101	000000000000000100000000	2		1	45.00	45.00	2		2		2							
H9947	005	2	1	04	01	H9947_005_2	13	6	DME/ASC	01	0000000000000000000001000111000010000		2		2			2		2		1		30		30			
H9947	005	2	1	04	01	H9947_005_2	13	5	$80	01	0000100000100100000000100000000000000		2		1	80.00	80.00	2		2		2							
H9947	005	2	1	04	01	H9947_005_2	13	4	PCP	01	0000001000001000000000000000000000000		2		1	30.00	30.00	2		2		2							
H9947	005	2	1	04	01	H9947_005_2	13	3	Outpatient	01	0000000000000000000010000000000000000		2		1	30.00	45.00	2		2		1		30		30			
H9947	005	2	1	04	01	H9947_005_2	13	13	Hearing	01	0000000000000000000000000000000000001		2		1	45.00	45.00	2		2		2							
H9947	005	2	1	04	01	H9947_005_2	13	14	Eye	10		000000000000000000001000	1	69.00	1	0.00	0.00	2		2		2							
H9947	005	2	1	04	01	H9947_005_2	13	15	Diag	01	0000000000000000010000000000000000000		2		1	150.00	170.00	2		2		2							
H9947	005	2	1	04	01	H9947_005_2	13	2	Therapeutic	01	0000000000000000001000000000000000000		2		2			2		1	2	1		25		25	1	30.00	45.00
H9947	801	0	1	04	01	H9947_801_0	8	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H9947	801	0	1	04	01	H9947_801_0	8	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H9947	802	0	1	04	01	H9947_802_0	8	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H9947	802	0	1	04	01	H9947_802_0	8	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H9947	803	0	1	04	01	H9947_803_0	7	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
H9947	803	0	1	04	01	H9947_803_0	7	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H9947	805	0	2	04	01	H9947_805_0	7	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
H9947	805	0	2	04	01	H9947_805_0	7	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
R3175	003	0	1	31	11	R3175_003_0	3	3	Group 3	11	0000000000000000000000000000000000010	000000000000000010000000	2		1	0.00	0.00	2		2		2							
R3175	003	0	1	31	11	R3175_003_0	3	1	Group 1	11	0111111111111110000011110111001101101	000001100000000000000000	2		2			2		2		1		30		30			
R3175	003	0	1	31	11	R3175_003_0	3	2	Group 2	01	0000000000000000000000000000010000000		2		2			2		2		1		0		30			
R3175	003	0	1	31	11	R3175_003_0	3	4	Group 4	01	0000000000000000000000001000100010000		2		2			2		2		1		20		20			
R3175	003	0	1	31	11	R3175_003_0	3	6	Group 6	10		000000000100000000000000	1	80.00	1	0.00	0.00	2		2		2							
R3175	003	0	1	31	11	R3175_003_0	3	5	Group 5	01	0000000000000001111100000000000000000		2		2			2		1	1	1	30	0	30	30	2		
R3175	801	0	1	31	11	R3175_801_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
R3175	801	0	1	31	11	R3175_801_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
R3175	802	0	1	31	11	R3175_802_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
R3175	802	0	1	31	11	R3175_802_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
R3332	001	0	1	31	11	R3332_001_0	11	1	50%	11	0111011111011011111111010111011111111	000000000000000010000000	2		2			2		2		1		50		50			
R3332	001	0	1	31	11	R3332_001_0	11	4	Dialysis	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
R3332	001	0	1	31	11	R3332_001_0	11	3	Ambulance	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
R3332	001	0	1	31	11	R3332_001_0	11	2	Mental Health	01	0000100000100100000000100000000000000		2		1	40.00	40.00	2		2		2							
R3444	008	0	1	31	11	R3444_008_0	3	1	Group 1	01	0111101111111110000011111110100011011		2		2			2		2		1		20		20			
R3444	008	0	1	31	11	R3444_008_0	3	2	Group 2	11	0000010000000000000000000000011100000	000001010000000010111010	2		1	0.00	0.00	2		2		2							
R3444	008	0	1	31	11	R3444_008_0	3	3	Group 3	10		000000000000000000000001	2		1	390.00	450.00	2		2		2							
R3444	008	0	1	31	11	R3444_008_0	3	4	Group 4	01	0000000000000000000000000000000000100		2		2			2		2		1		0		20			
R3444	008	0	1	31	11	R3444_008_0	3	7	Group 7	10		000000000100000000000000	1	25.00	1	0.00	0.00	2		2		2							
R3444	008	0	1	31	11	R3444_008_0	3	6	Group 6	10		000000000000000000000100	1	125.00	1	0.00	0.00	2		2		2							
R3444	008	0	1	31	11	R3444_008_0	3	5	Group 5	01	0000000000000001111100000000000000000		2		2			2		1	1	1	20	20	20	20	2		
R3444	008	0	1	31	11	R3444_008_0	3	8	Group 8	01	0000000000000000000000000001000000000		2		2			2		2		1		20		30			
R3444	009	0	1	31	11	R3444_009_0	5	15	Group15	01	0000000010000010000000000000000000000		2		1	40.00	40.00	2		2		2							
R3444	009	0	1	31	11	R3444_009_0	5	14	Group 14	01	0000000000001000000000000000000000000		2		1	25.00	50.00	2		2		2							
R3444	009	0	1	31	11	R3444_009_0	5	13	Group 13	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
R3444	009	0	1	31	11	R3444_009_0	5	12	Group 12	10		000000000000000000000001	2		1	390.00	450.00	2		2		2							
R3444	009	0	1	31	11	R3444_009_0	5	11	Group 11	11	0000000000010000000000010000011100010	000001110000000010010000	2		1	0.00	0.00	2		2		2							
R3444	009	0	1	31	11	R3444_009_0	5	10	Group 10	01	0000000000000000000000000000000000100		2		1	0.00	50.00	2		2		2							
R3444	009	0	1	31	11	R3444_009_0	5	1	Group 1	01	0111000001000000000000000000000001001		2		1	50.00	50.00	2		2		2							
R3444	009	0	1	31	11	R3444_009_0	5	2	Group 2	01	0000010000000000000000000100000000000		2		2			2		2		1		50		50			
R3444	009	0	1	31	11	R3444_009_0	5	9	Group 9	01	0000000000000001111100000000000000000		2		1	15.00	16.00	2		1	2	1		20		20	1	25.00	50.00
R3444	009	0	1	31	11	R3444_009_0	5	8	Group 8	01	0000000000000000000011000011100010000		2		2			2		2		1		20		20			
R3444	009	0	1	31	11	R3444_009_0	5	7	Group 7	11	0000001000000000000000000000000000000	000000000000000000001010	2		1	25.00	25.00	2		2		2							
R3444	009	0	1	31	11	R3444_009_0	5	6	Group 6	01	0000000000100100000000100000000000000		2		1	30.00	40.00	2		2		2							
R3444	009	0	1	31	11	R3444_009_0	5	5	Group 5	10		000000000000000000000100	1	100.00	1	0.00	0.00	2		2		2							
R3444	009	0	1	31	11	R3444_009_0	5	4	Group 4	11	0000000100000000000000000000000000000	000000000000000000100000	2		1	20.00	20.00	2		2		2							
R3444	009	0	1	31	11	R3444_009_0	5	3	Group 3	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
R3444	011	0	1	31	11	R3444_011_0	3	7	Group 7	01	0000000000000000000000000001000000000		2		2			2		2		1		20		30			
R3444	011	0	1	31	11	R3444_011_0	3	6	Group 6	10		000000000000000000000100	1	125.00	1	0.00	0.00	2		2		2							
R3444	011	0	1	31	11	R3444_011_0	3	5	Group 5	01	0000000000000001111100000000000000000		2		2			2		1	1	1	20	20	20	20	2		
R3444	011	0	1	31	11	R3444_011_0	3	4	Group  4	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
R3444	011	0	1	31	11	R3444_011_0	3	3	Group 3	01	0000000000000000000000000000000000100		2		2			2		2		1		0		20			
R3444	011	0	1	31	11	R3444_011_0	3	2	Group 2	11	0000010000000000000000000000011100000	000001010000000010111010	2		1	0.00	0.00	2		2		2							
R3444	011	0	1	31	11	R3444_011_0	3	1	Group 1	01	0111101111111110000011111110100011011		2		2			2		2		1		20		20			
R3444	012	0	1	31	11	R3444_012_0	4	8	Group 8	01	0000000000000000000011000011100010000		2		2			2		2		1		20		20			
R3444	012	0	1	31	11	R3444_012_0	4	7	Group 7	10		000000000000000000001000	2		1	25.00	25.00	2		2		2							
R3444	012	0	1	31	11	R3444_012_0	4	6	Group 6	01	0000000010100110000000100000000000000		2		1	30.00	40.00	2		2		2							
R3444	012	0	1	31	11	R3444_012_0	4	5	Group 5	10		000000000000000000000100	1	100.00	1	0.00	0.00	2		2		2							
R3444	012	0	1	31	11	R3444_012_0	4	4	Group 4	11	0000001000000000000000000000000000000	000000000000000000000010	2		1	30.00	30.00	2		2		2							
R3444	012	0	1	31	11	R3444_012_0	4	3	Group 3	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
R3444	012	0	1	31	11	R3444_012_0	4	2	Group 2	01	0000010000000000000000000000000000000		2		2			2		2		1		50		50			
R3444	012	0	1	31	11	R3444_012_0	4	15	Group 15	01	0000000000000000000000000100000000000		2		2			2		2		1		40		40			
R3444	012	0	1	31	11	R3444_012_0	4	14	Group 14	01	0000000000000000000000000000000000100		2		1	0.00	50.00	2		2		2							
R3444	012	0	1	31	11	R3444_012_0	4	13	Group 13	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
R3444	012	0	1	31	11	R3444_012_0	4	9	Group 9	01	0000000000000001111100000000000000000		2		1	15.00	16.00	2		1	2	1		20		20	1	30.00	50.00
R3444	012	0	1	31	11	R3444_012_0	4	11	Group 11	11	0000000000000000000000010000011100010	000000100000000110010000	2		1	0.00	0.00	2		2		2							
R3444	012	0	1	31	11	R3444_012_0	4	10	Group 10	11	0000000100000000000000000000000000000	000000000000000000100000	2		1	20.00	20.00	2		2		2							
R3444	012	0	1	31	11	R3444_012_0	4	1	Group 1	11	0111000001011000000000000000000001001	000001000000000000000000	2		1	50.00	50.00	2		2		2							
R3444	012	0	1	31	11	R3444_012_0	4	12	Group 12	10		000000000000000000000001	2		1	390.00	450.00	2		2		2							
R5287	001	0	1	31	11	R5287_001_0	3	10	Group 10	01	0000010000000000000000000100000010000		2		2			2		2		1		50		50			
R5287	001	0	1	31	11	R5287_001_0	3	1	Group 1	11	0111000111010010000000000000000001101	000001000000000000001010	2		1	70.00	70.00	2		2		2							
R5287	001	0	1	31	11	R5287_001_0	3	9	Group 9	11	0000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
R5287	001	0	1	31	11	R5287_001_0	3	8	Group 8	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
R5287	001	0	1	31	11	R5287_001_0	3	7	Group 7	01	0000000000100100000000100000000000000		2		1	35.00	45.00	2		2		2							
R5287	001	0	1	31	11	R5287_001_0	3	6	Group 6	01	0000000000000000000000001000000000000		2		1	300.00	300.00	2		2		2							
R5287	001	0	1	31	11	R5287_001_0	3	5	Group 5	01	0000100000000000000000000000000000000		2		1	75.00	75.00	2		2		2							
R5287	001	0	1	31	11	R5287_001_0	3	4	Group 4	10		000000000000000000000001	2		1	390.00	450.00	2		2		2							
R5287	001	0	1	31	11	R5287_001_0	3	3	Group 3	01	0000000000000001111100000000000000000		2		1	22.00	30.00	2		1	2	1		40		40	1	45.00	70.00
R5287	001	0	1	31	11	R5287_001_0	3	2	Group 2	11	0000000000000000000011000011001100010	000000000000000100000000	2		2			2		2		1		40		40			
R5287	001	0	1	31	11	R5287_001_0	3	13	Group 13	01	0000000000001000000000000000000000000		2		1	45.00	70.00	2		2		2							
R5287	001	0	1	31	11	R5287_001_0	3	12	Group 12	01	0000001000000000000000000000000000000		2		1	45.00	45.00	2		2		2							
R5287	001	0	1	31	11	R5287_001_0	3	11	Group 11	01	0000000000000000000000000000010000000		2		2			2		2		1		0		40			
R5287	002	0	1	31	11	R5287_002_0	2	11	Group 11	01	0000000000000000000000000000010000000		2		2			2		2		1		0		40			
R5287	002	0	1	31	11	R5287_002_0	2	10	Group 10	01	0000010000000000000000000100000010000		2		2			2		2		1		50		50			
R5287	002	0	1	31	11	R5287_002_0	2	1	Group 1	11	0111000111010010000000000000000001101	000001000000000000001010	2		1	70.00	70.00	2		2		2							
R5287	002	0	1	31	11	R5287_002_0	2	3	Group 3	01	0000000000000001111100000000000000000		2		1	21.00	30.00	2		1	2	1		40		40	1	45.00	70.00
R5287	002	0	1	31	11	R5287_002_0	2	2	Group 2	11	0000000000000000000011000011001100010	000000000000000100000000	2		2			2		2		1		40		40			
R5287	002	0	1	31	11	R5287_002_0	2	13	Group 13	01	0000000000001000000000000000000000000		2		1	45.00	70.00	2		2		2							
R5287	002	0	1	31	11	R5287_002_0	2	4	Group 4	10		000000000000000000000001	2		1	390.00	450.00	2		2		2							
R5287	002	0	1	31	11	R5287_002_0	2	5	Group 5	01	0000100000000000000000000000000000000		2		1	75.00	75.00	2		2		2							
R5287	002	0	1	31	11	R5287_002_0	2	6	Group 6	01	0000000000000000000000001000000000000		2		1	300.00	300.00	2		2		2							
R5287	002	0	1	31	11	R5287_002_0	2	7	Group 7	01	0000000000100100000000100000000000000		2		1	35.00	45.00	2		2		2							
R5287	002	0	1	31	11	R5287_002_0	2	8	Group 8	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
R5287	002	0	1	31	11	R5287_002_0	2	9	Group 9	11	0000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
R5287	002	0	1	31	11	R5287_002_0	2	12	Group 12	01	0000001000000000000000000000000000000		2		1	45.00	45.00	2		2		2							
R5287	003	0	1	31	11	R5287_003_0	3	2	Group 2	01	0000000000000000000000000000010000000		2		2			2		2		1		0		40			
R5287	003	0	1	31	11	R5287_003_0	3	1	Group 1	11	0111111111111110000011110111001111101	000001100000000000000000	2		2			2		2		1		40		40			
R5287	003	0	1	31	11	R5287_003_0	3	8	Group 8	10		000000000100000000000000	1	35.00	1	0.00	0.00	2		2		2							
R5287	003	0	1	31	11	R5287_003_0	3	7	Group 7	01	0000000000000001111100000000000000000		2		2			2		1	1	1	40	0	40	40	2		
R5287	003	0	1	31	11	R5287_003_0	3	6	Group 6	10		000000010000000000000000	2		2			2		2		1		75		75			
R5287	003	0	1	31	11	R5287_003_0	3	3	Group 3	01	0000000000000000000000001000100000000		2		2			2		2		1		20		20			
R5287	003	0	1	31	11	R5287_003_0	3	4	Group 4	01	0000000000000000000000000000000000010		2		1	0.00	0.00	2		2		2							
R5287	003	0	1	31	11	R5287_003_0	3	5	Group 5	10		000000000000000000100000	2		1	40.00	40.00	2		2		2							
R5342	001	0	1	31	11	R5342_001_0	2	10	Group 10	11	0000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
R5342	001	0	1	31	11	R5342_001_0	2	1	Group 1	01	0000001000000000000000000000000000000		2		1	45.00	45.00	2		2		2							
R5342	001	0	1	31	11	R5342_001_0	2	11	Group 11	01	0000000000000000000000000000010000000		2		2			2		2		1		0		40			
R5342	001	0	1	31	11	R5342_001_0	2	12	Group 12	01	0000010000000000000000000100000000000		2		2			2		2		1		50		50			
R5342	001	0	1	31	11	R5342_001_0	2	13	Group 13	01	0000000000001000000000000000000000000		2		1	45.00	65.00	2		2		2							
R5342	001	0	1	31	11	R5342_001_0	2	2	Group 2	11	0111000111010010000000000000000001101	000001000000000000001010	2		1	65.00	65.00	2		2		2							
R5342	001	0	1	31	11	R5342_001_0	2	9	Group 9	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
R5342	001	0	1	31	11	R5342_001_0	2	4	Group 4	01	0000000000000001111100000000000000000		2		1	13.00	21.00	2		1	2	1		40		40	1	45.00	65.00
R5342	001	0	1	31	11	R5342_001_0	2	5	Group 5	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
R5342	001	0	1	31	11	R5342_001_0	2	6	Group 6	01	0000100000000000000000000000000000000		2		1	75.00	75.00	2		2		2							
R5342	001	0	1	31	11	R5342_001_0	2	7	Group 7	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
R5342	001	0	1	31	11	R5342_001_0	2	8	Group 8	01	0000000000100100000000100000000000000		2		1	35.00	45.00	2		2		2							
R5342	001	0	1	31	11	R5342_001_0	2	3	Group 3	11	0000000000000000000011000011001110010	000000000000000100000000	2		2			2		2		1		40		40			
R5342	002	0	1	31	11	R5342_002_0	2	10	Group 10	11	0000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
R5342	002	0	1	31	11	R5342_002_0	2	1	Group 1	01	0000001000000000000000000000000000000		2		1	45.00	45.00	2		2		2							
R5342	002	0	1	31	11	R5342_002_0	2	11	Group 11	01	0000000000000000000000000000010000000		2		2			2		2		1		0		40			
R5342	002	0	1	31	11	R5342_002_0	2	9	Group 9	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
R5342	002	0	1	31	11	R5342_002_0	2	8	Group 8	01	0000000000100100000000100000000000000		2		1	35.00	45.00	2		2		2							
R5342	002	0	1	31	11	R5342_002_0	2	7	Group 7	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
R5342	002	0	1	31	11	R5342_002_0	2	6	Group 6	01	0000100000000000000000000000000000000		2		1	75.00	75.00	2		2		2							
R5342	002	0	1	31	11	R5342_002_0	2	5	Group 5	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
R5342	002	0	1	31	11	R5342_002_0	2	12	Group 12	01	0000010000000000000000000100000000000		2		2			2		2		1		50		50			
R5342	002	0	1	31	11	R5342_002_0	2	13	Group 13	01	0000000000001000000000000000000000000		2		1	45.00	65.00	2		2		2							
R5342	002	0	1	31	11	R5342_002_0	2	2	Group 2	11	0111000111010010000000000000000001101	000001000000000000001010	2		1	65.00	65.00	2		2		2							
R5342	002	0	1	31	11	R5342_002_0	2	3	Group 3	11	0000000000000000000011000011001110010	000000000000000100000000	2		2			2		2		1		40		40			
R5342	002	0	1	31	11	R5342_002_0	2	4	Group 4	01	0000000000000001111100000000000000000		2		1	13.00	21.00	2		1	2	1		40		40	1	45.00	65.00
R5342	801	0	1	31	11	R5342_801_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
R5342	801	0	1	31	11	R5342_801_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
R5342	802	0	1	31	11	R5342_802_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
R5342	802	0	1	31	11	R5342_802_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
R5342	803	0	1	31	11	R5342_803_0	2	1		01	0000010000000000000000000000010000000		2		2			2		2		1		0		0			
R5342	803	0	1	31	11	R5342_803_0	2	2		01	0111101111111111111111111111101111111		2		2			2		2		1		20		20			
R5826	001	0	1	31	11	R5826_001_0	3	1		11	0000000000000000000000010000000000010	000000100000000000000000	2		1	0.00	0.00	2		2		2							
R5826	001	0	1	31	11	R5826_001_0	3	10		10		000000000010000010000000	2		2			2		2		1		50		50			
R5826	001	0	1	31	11	R5826_001_0	3	9		11	0111111111111111111101100000001101101	000000000000000100000000	2		2			2		2		1		40		40			
R5826	001	0	1	31	11	R5826_001_0	3	8		01	0000000000000000000000000010000000000		2		2			2		2		1		25		25			
R5826	001	0	1	31	11	R5826_001_0	3	7		01	0000000000000000000010000000000010000		2		2			2		2		1		20		40			
R5826	001	0	1	31	11	R5826_001_0	3	6		01	0000000000000000000000000101100000000		2		2			2		2		1		20		20			
R5826	001	0	1	31	11	R5826_001_0	3	5		01	0000000000000000000000000000010000000		2		2			2		2		1		0		40			
R5826	001	0	1	31	11	R5826_001_0	3	4		01	0000000000000000000000001000000000000		2		1	300.00	300.00	2		2		2							
R5826	001	0	1	31	11	R5826_001_0	3	3		10		000000000000000000001000	1	40.00	1	0.00	0.00	2		2		2							
R5826	001	0	1	31	11	R5826_001_0	3	11		10		000000000100000000000000	1	20.00	2			2		2		1		50		50			
R5826	001	0	1	31	11	R5826_001_0	3	2		10		000000000000000000000100	1	100.00	1	0.00	0.00	2		2		2							
R5826	002	0	1	31	11	R5826_002_0	3	5		01	0000000000000000000000000000010000000		2		2			2		2		1		0		20			
R5826	002	0	1	31	11	R5826_002_0	3	4		01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
R5826	002	0	1	31	11	R5826_002_0	3	3		10		000000000000000000001000	1	40.00	1	0.00	0.00	2		2		2							
R5826	002	0	1	31	11	R5826_002_0	3	2		10		000000000000000000000100	1	100.00	1	0.00	0.00	2		2		2							
R5826	002	0	1	31	11	R5826_002_0	3	1		11	0000000000000000000000010000000000010	000000100000000000000000	2		1	0.00	0.00	2		2		2							
R5826	002	0	1	31	11	R5826_002_0	3	7		10		000000000010000010100000	2		2			2		2		1		50		50			
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R5826	002	0	1	31	11	R5826_002_0	3	8		10		000000000100000000000000	1	20.00	2			2		2		1		50		50			
R5826	005	0	1	31	11	R5826_005_0	3	4		11	0000001101111100000000000000001001101	000000000000000100000000	2		1	45.00	45.00	2		2		2							
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R5826	005	0	1	31	11	R5826_005_0	3	8		01	0000000000000000000000000100000000000		2		2			2		2		1		30		30			
R5826	005	0	1	31	11	R5826_005_0	3	9		01	0000110000000000000001100001000000000		2		2			2		2		1		40		40			
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R5826	005	0	1	31	11	R5826_005_0	3	10		01	0000000000000000000000000000010000000		2		1	0.00	45.00	2		2		1		40		40			
R5826	005	0	1	31	11	R5826_005_0	3	11		01	0000000000000000010000000000000000000		2		1	175.00	175.00	2		1	2	1		40		40	1	45.00	45.00
R5826	005	0	1	31	11	R5826_005_0	3	12		01	0111000010000011101100000000000100000		2		1	45.00	45.00	2		2		1		40		40			
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R5826	006	0	1	31	11	R5826_006_0	3	2		10		000000000000000000001000	1	40.00	1	0.00	0.00	2		2		2							
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R6801	009	0	1	31	11	R6801_009_0	4	3	Group 3	01	0000010000000000000000000100000000000		2		2			2		2		1		50		50			
R6801	009	0	1	31	11	R6801_009_0	4	4	Group 4	11	0000001000000000000000000000000000000	000000000000000000000010	2		1	15.00	15.00	2		2		2							
R6801	009	0	1	31	11	R6801_009_0	4	5	Group 5	01	0000000000001000000000000000000000000		2		1	15.00	45.00	2		2		2							
R6801	009	0	1	31	11	R6801_009_0	4	6	Group 6	01	0000000000100100000000100000000000000		2		1	30.00	40.00	2		2		2							
R6801	009	0	1	31	11	R6801_009_0	4	7	Group 7	10		000000000000000000000001	2		1	390.00	450.00	2		2		2							
R6801	009	0	1	31	11	R6801_009_0	4	8	Group 8	01	0000000000000000000011000011100010000		2		2			2		2		1		20		20			
R6801	009	0	1	31	11	R6801_009_0	4	2	Group 2	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
R6801	009	0	1	31	11	R6801_009_0	4	14	Group 14	01	0000000010000010000000000000000000000		2		1	40.00	40.00	2		2		2							
R6801	009	0	1	31	11	R6801_009_0	4	13	Group 13	01	0000000100000000000000000000000000000		2		1	20.00	20.00	2		2		2							
R6801	009	0	1	31	11	R6801_009_0	4	12	Group 12	01	0000000000000000000000000000000000100		2		1	0.00	45.00	2		2		2							
R6801	009	0	1	31	11	R6801_009_0	4	11	Group 11	11	0000000000010000000000010000011100010	000001110000000010000000	2		1	0.00	0.00	2		2		2							
R6801	009	0	1	31	11	R6801_009_0	4	10	Group 10	01	0000000000000000000000001000000000000		2		1	300.00	300.00	2		2		2							
R6801	009	0	1	31	11	R6801_009_0	4	1	Group 1	11	0111000001000000000000000000000001001	000000000000000000001000	2		1	45.00	45.00	2		2		2							
R6801	009	0	1	31	11	R6801_009_0	4	9	Group 9	01	0000000000000001111100000000000000000		2		1	20.00	24.00	2		1	2	1		20		20	1	15.00	45.00
R6801	011	0	1	31	11	R6801_011_0	3	2	Group 2	11	0000010000000000000000000000011100000	000000010000000010000010	2		1	0.00	0.00	2		2		2							
R6801	011	0	1	31	11	R6801_011_0	3	1	Group 1	01	0111101111111110000011111110100011011		2		2			2		2		1		20		20			
R6801	011	0	1	31	11	R6801_011_0	3	6	Group 6	01	0000000000000000000000000001000000000		2		2			2		2		1		20		30			
R6801	011	0	1	31	11	R6801_011_0	3	5	Group 5	01	0000000000000001111100000000000000000		2		2			2		1	1	1	20	20	20	20	2		
R6801	011	0	1	31	11	R6801_011_0	3	4	Group  4	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
R6801	011	0	1	31	11	R6801_011_0	3	3	Group 3	01	0000000000000000000000000000000000100		2		2			2		2		1		0		20			
R6801	012	0	1	31	11	R6801_012_0	5	15	Group 15	01	0000000000001000000000000000000000000		2		1	15.00	45.00	2		2		2							
R6801	012	0	1	31	11	R6801_012_0	5	2	Group 2	01	0000010000000000000000000000000000000		2		2			2		2		1		50		50			
R6801	012	0	1	31	11	R6801_012_0	5	3	Group 3	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
R6801	012	0	1	31	11	R6801_012_0	5	4	Group 4	11	0000000100000000000000000000000000000	000000000000000000100000	2		1	20.00	20.00	2		2		2							
R6801	012	0	1	31	11	R6801_012_0	5	5	Group 5	11	0000001000000000000000000000000000000	000000000000000000000010	2		1	15.00	15.00	2		2		2							
R6801	012	0	1	31	11	R6801_012_0	5	6	Group 6	01	0000000000100100000000100000000000000		2		1	30.00	40.00	2		2		2							
R6801	012	0	1	31	11	R6801_012_0	5	7	Group 7	01	0000000000000000000000000100000000000		2		2			2		2		1		40		40			
R6801	012	0	1	31	11	R6801_012_0	5	8	Group 8	01	0000000000000000000011000011100010000		2		2			2		2		1		20		20			
R6801	012	0	1	31	11	R6801_012_0	5	14	Group 14	01	0000000010000010000000000000000000000		2		1	40.00	40.00	2		2		2							
R6801	012	0	1	31	11	R6801_012_0	5	9	Group 9	01	0000000000000001111100000000000000000		2		1	13.00	24.00	2		1	2	1		20		20	1	15.00	45.00
R6801	012	0	1	31	11	R6801_012_0	5	12	Group 12	10		000000000000000000000001	2		1	390.00	450.00	2		2		2							
R6801	012	0	1	31	11	R6801_012_0	5	11	Group 11	11	0000000000000000000000010000011100010	000000100000000110010000	2		1	0.00	0.00	2		2		2							
R6801	012	0	1	31	11	R6801_012_0	5	10	Group 10	01	0000000000000000000000000000000000100		2		1	0.00	45.00	2		2		2							
R6801	012	0	1	31	11	R6801_012_0	5	1	Group 1	11	0111000001010000000000000000000001001	000001000000000000001000	2		1	45.00	45.00	2		2		2							
R6801	012	0	1	31	11	R6801_012_0	5	13	Group 13	01	0000000000000000000000001000000000000		2		1	300.00	300.00	2		2		2							
R7444	001	0	1	31	11	R7444_001_0	2	1	Group 1	11	0111001111011010000011000011001111111	000001000000000100001010	2		2			2		2		1		40		40			
R7444	001	0	1	31	11	R7444_001_0	2	10	Group 10	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
R7444	001	0	1	31	11	R7444_001_0	2	2	Group 2	11	0000000000000000000000010000000000000	000000100000000010000000	2		1	0.00	0.00	2		2		2							
R7444	001	0	1	31	11	R7444_001_0	2	3	Group 3	01	0000010000000000000000000100000000000		2		2			2		2		1		50		50			
R7444	001	0	1	31	11	R7444_001_0	2	9	Group 9	01	0000000000000000000000000000010000000		2		2			2		2		1		0		40			
R7444	001	0	1	31	11	R7444_001_0	2	5	Group 5	01	0000000000000001111100000000000000000		2		1	13.00	13.00	2		1	1	1	40	40	40	40	2		
R7444	001	0	1	31	11	R7444_001_0	2	6	Group 6	01	0000000000100100000000100000000000000		2		1	35.00	45.00	2		2		2							
R7444	001	0	1	31	11	R7444_001_0	2	7	Group 7	01	0000100000000000000000000000000000000		2		1	75.00	75.00	2		2		2							
R7444	001	0	1	31	11	R7444_001_0	2	8	Group 8	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
R7444	001	0	1	31	11	R7444_001_0	2	4	Group 4	01	0000000000000000000000000000100000000		2		2			2		2		1		20		20			
R9896	008	0	1	31	11	R9896_008_0	4	1	Group 1	01	0111101111111110000011111110100011011		2		2			2		2		1		20		20			
R9896	008	0	1	31	11	R9896_008_0	4	2	Group 2	11	0000010000000000000000000000011100000	000001010000000000111011	2		1	0.00	0.00	2		2		2							
R9896	008	0	1	31	11	R9896_008_0	4	3	Group 3	01	0000000000000000000000000001000000000		2		2			2		2		1		20		30			
R9896	008	0	1	31	11	R9896_008_0	4	4	Group 4	01	0000000000000000000000000000000000100		2		2			2		2		1		0		20			
R9896	008	0	1	31	11	R9896_008_0	4	5	Group 5	01	0000000000000001111100000000000000000		2		2			2		1	1	1	20	20	20	20	2		
R9896	008	0	1	31	11	R9896_008_0	4	6	Group 6	10		000000000000000000000100	1	125.00	1	0.00	0.00	2		2		2							
R9896	008	0	1	31	11	R9896_008_0	4	7	Group 7	10		000000000100000000000000	1	30.00	1	0.00	0.00	2		2		2							
R9896	009	0	1	31	11	R9896_009_0	5	3	Group 3	01	0000010000000000000000000100000000000		2		2			2		2		1		50		50			
R9896	009	0	1	31	11	R9896_009_0	5	4	Group 4	10		000000000000000000000100	1	100.00	1	0.00	0.00	2		2		2							
R9896	009	0	1	31	11	R9896_009_0	5	5	Group 5	11	0000000100000000000000000000000000000	000000000000000000100000	2		1	20.00	20.00	2		2		2							
R9896	009	0	1	31	11	R9896_009_0	5	6	Group 6	01	0000000000100100000000100000000000000		2		1	30.00	40.00	2		2		2							
R9896	009	0	1	31	11	R9896_009_0	5	7	Group 7	01	0000000000000000000000000000000000100		2		1	0.00	50.00	2		2		2							
R9896	009	0	1	31	11	R9896_009_0	5	8	Group 8	01	0000000000000000000011000011100010000		2		2			2		2		1		20		20			
R9896	009	0	1	31	11	R9896_009_0	5	9	Group 9	01	0000000000000001111100000000000000000		2		1	20.00	25.00	2		1	2	1		20		20	1	25.00	50.00
R9896	009	0	1	31	11	R9896_009_0	5	2	Group 2	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
R9896	009	0	1	31	11	R9896_009_0	5	15	Group 15	01	0000000010000010000000000000000000000		2		1	40.00	40.00	2		2		2							
R9896	009	0	1	31	11	R9896_009_0	5	14	Group 14	01	0000000000001000000000000000000000000		2		1	25.00	50.00	2		2		2							
R9896	009	0	1	31	11	R9896_009_0	5	13	Group 13	10		000000000000000000000001	2		1	390.00	450.00	2		2		2							
R9896	009	0	1	31	11	R9896_009_0	5	12	Group 12	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
R9896	009	0	1	31	11	R9896_009_0	5	11	Group 11	11	0000000000010000000000010000011100010	000001110000000010010000	2		1	0.00	0.00	2		2		2							
R9896	009	0	1	31	11	R9896_009_0	5	1	Group 1	01	0111000001000000000000000000000001001		2		1	50.00	50.00	2		2		2							
R9896	009	0	1	31	11	R9896_009_0	5	10	Group 10	11	0000001000000000000000000000000000000	000000000000000000001010	2		1	25.00	25.00	2		2		2							
R9896	012	0	1	31	11	R9896_012_0	5	2	Group 2	01	0000000010100110000000100000000000000		2		1	30.00	40.00	2		2		2							
R9896	012	0	1	31	11	R9896_012_0	5	15	Group 15	01	0000000000000000000000000100000000000		2		2			2		2		1		40		40			
R9896	012	0	1	31	11	R9896_012_0	5	4	Group 4	11	0000001000000000000000000000000000000	000000000000000000000010	2		1	30.00	30.00	2		2		2							
R9896	012	0	1	31	11	R9896_012_0	5	5	Group 5	11	0000000100000000000000000000000000000	000000000000000000100000	2		1	20.00	20.00	2		2		2							
R9896	012	0	1	31	11	R9896_012_0	5	6	Group 6	01	0000000000000001111100000000000000000		2		1	15.00	19.00	2		1	2	1		20		20	1	30.00	50.00
R9896	012	0	1	31	11	R9896_012_0	5	7	Group 7	10		000000000000000000000100	1	100.00	1	0.00	0.00	2		2		2							
R9896	012	0	1	31	11	R9896_012_0	5	8	Group 8	01	0000000000000000000011000011100010000		2		2			2		2		1		20		20			
R9896	012	0	1	31	11	R9896_012_0	5	9	Group 9	01	0000000000000000000000000000000000100		2		1	0.00	50.00	2		2		2							
R9896	012	0	1	31	11	R9896_012_0	5	3	Group 3	01	0000010000000000000000000000000000000		2		2			2		2		1		50		50			
R9896	012	0	1	31	11	R9896_012_0	5	1	Group 1	11	0111000001011000000000000000000001001	000001000000000000000000	2		1	50.00	50.00	2		2		2							
R9896	012	0	1	31	11	R9896_012_0	5	10	Group 10	01	0000100000000000000000000000000000000		2		1	55.00	55.00	2		2		2							
R9896	012	0	1	31	11	R9896_012_0	5	11	Group 11	11	0000000000000000000000010000011100010	000000100000000110010000	2		1	0.00	0.00	2		2		2							
R9896	012	0	1	31	11	R9896_012_0	5	12	Group 12	01	0000000000000000000000001000000000000		2		1	250.00	250.00	2		2		2							
R9896	012	0	1	31	11	R9896_012_0	5	13	Group 13	10		000000000000000000000001	2		1	390.00	450.00	2		2		2							
R9896	012	0	1	31	11	R9896_012_0	5	14	Group 14	10		000000000000000000001000	2		1	25.00	25.00	2		2		2							
R9896	021	0	1	31	11	R9896_021_0	4	7	Group 7	01	0000000000000000000000000001000000000		2		2			2		2		1		20		30			
R9896	021	0	1	31	11	R9896_021_0	4	6	Group 6	10		000000000000000000000100	1	70.00	1	0.00	0.00	2		2		2							
R9896	021	0	1	31	11	R9896_021_0	4	5	Group 5	01	0000000000000001111100000000000000000		2		2			2		1	1	1	20	20	20	20	2		
R9896	021	0	1	31	11	R9896_021_0	4	4	Group  4	10		000000000000000000000001	2		1	330.00	380.00	2		2		2							
R9896	021	0	1	31	11	R9896_021_0	4	3	Group 3	01	0000000000000000000000000000000000100		2		2			2		2		1		0		20			
R9896	021	0	1	31	11	R9896_021_0	4	2	Group 2	11	0000010000000000000000000000011100000	000000010000000000001010	2		1	0.00	0.00	2		2		2							
R9896	021	0	1	31	11	R9896_021_0	4	1	Group 1	01	0111101111111110000011111110100011011		2		2			2		2		1		20		20			
