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_coins_yn	pbp_c_oon_outpt_coins_min_pct	pbp_c_oon_outpt_coins_max_pct
H0104	012	0	1	04	01	H0104_012_0	3	1		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;16b;17a;17b;18a;	9d;14c;	2		2			2		1	40	40
H0104	012	0	1	04	01	H0104_012_0	3	4		10		17a;	2		2			2		2		
H0104	012	0	1	04	01	H0104_012_0	3	3		01	8a1;8a2;8b1;8b2;8b3;14e;		2		2			2		1	40	40
H0104	012	0	1	04	01	H0104_012_0	3	2		01	10a;		2		1	200.00	200.00	2		2		
H0104	013	0	1	04	01	H0104_013_0	3	4		10		17a;	2		2			2		2		
H0104	013	0	1	04	01	H0104_013_0	3	3		01	8a1;8a2;8b1;8b2;8b3;14e;		2		2			2		1	40	40
H0104	013	0	1	04	01	H0104_013_0	3	2		01	10a;		2		1	200.00	200.00	2		2		
H0104	013	0	1	04	01	H0104_013_0	3	1		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;16b;17a;17b;18a;	9d;14c;	2		2			2		1	40	40
H0104	014	0	1	04	01	H0104_014_0	3	2		01	10a;		2		1	250.00	250.00	2		2		
H0104	014	0	1	04	01	H0104_014_0	3	1		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;16b;17a;17b;18a;	9d;14c;	2		2			2		1	40	40
H0104	014	0	1	04	01	H0104_014_0	3	3		01	8a1;8a2;8b1;8b2;8b3;14e;		2		2			2		1	40	40
H0104	014	0	1	04	01	H0104_014_0	3	4		10		17a;	2		2			2		2		
H0104	015	0	1	04	01	H0104_015_0	4	1		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;16b;17a;17b;18a;	9d;14c;	2		2			2		1	40	40
H0104	015	0	1	04	01	H0104_015_0	4	2	Ambulance Services	01	10a;		2		1	200.00	200.00	2		2		
H0104	015	0	1	04	01	H0104_015_0	4	3		01	8a1;8a2;8b1;8b2;8b3;14e;		2		2			2		1	40	40
H0104	015	0	1	04	01	H0104_015_0	4	4		10		17a;	2		2			2		2		
H0104	801	0	1	04	01	H0104_801_0	1	1		01	6;14a;		2		2			2		1	0	0
H0104	801	0	1	04	01	H0104_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H0104	802	0	1	04	01	H0104_802_0	1	1		01	6;14a;		2		2			2		1	0	0
H0104	802	0	1	04	01	H0104_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H0104	804	0	1	04	01	H0104_804_0	1	1		01	6;14a;		2		2			2		1	0	0
H0104	804	0	1	04	01	H0104_804_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H0107	001	0	1	04	01	H0107_001_0	10	6	$100 Copay	01	10a;		2		1	100.00	100.00	2		2		
H0107	001	0	1	04	01	H0107_001_0	10	5	$350 Copay	01	9a;9b;		2		1	350.00	350.00	2		2		
H0107	001	0	1	04	01	H0107_001_0	10	4	$40 Copay	01	7a;7b;		2		1	40.00	40.00	2		2		
H0107	001	0	1	04	01	H0107_001_0	10	3	$60 Copay	01	5;7e;7h;9c;		2		1	60.00	60.00	2		2		
H0107	001	0	1	04	01	H0107_001_0	10	2	65 Copay	01	7d;7f;7g;7i;16b;17a;		2		1	65.00	65.00	2		2		
H0107	001	0	1	04	01	H0107_001_0	10	12	OTC	10		13b;	1	10.00	2			2		2		
H0107	001	0	1	04	01	H0107_001_0	10	11	$400 Allowance	10		18b;	2		2			2		2		
H0107	001	0	1	04	01	H0107_001_0	10	10	$175 Allowance	10		17b;	2		2			2		2		
H0107	001	0	1	04	01	H0107_001_0	10	1	20%	01	3-1;3-2;3-3;7c;8a1;8a2;8b1;8b2;8b3;11a;11b;11c;12;14e;15;		2		2			2		1	20	20
H0107	001	0	1	04	01	H0107_001_0	10	7	$0	11	6;9d;14a;14d;	14c;16a;	2		1	0.00	0.00	2		2		
H0107	001	0	1	04	01	H0107_001_0	10	9	$40 Allowance	10		17a;	2		2			2		2		
H0107	001	0	1	04	01	H0107_001_0	10	8	40% Coinsurance	11	17b;18a;	14b;18a;	2		2			2		1	40	40
H0107	002	0	1	04	01	H0107_002_0	10	1	20% Coinsurance	01	3-1;3-2;3-3;7c;8a1;8a2;8b1;8b2;8b3;11a;11b;11c;12;14e;15;16b;17b;		2		2			2		1	20	20
H0107	002	0	1	04	01	H0107_002_0	10	10	$175 Allowance - Eyewear	10		17b;	2		2			2		2		
H0107	002	0	1	04	01	H0107_002_0	10	11	Comprehensive Dental  $1000 Allowance	10		16b;	2		2			2		2		
H0107	002	0	1	04	01	H0107_002_0	10	2	$65 Copay	01	17a;		2		1	65.00	65.00	2		2		
H0107	002	0	1	04	01	H0107_002_0	10	3	$45 Copay	11	5;7d;7e;7f;7g;7h;7i;9c;18a;	14b;18a;	2		1	45.00	45.00	2		2		
H0107	002	0	1	04	01	H0107_002_0	10	4	$40 Allowance - Routine Eye Exam	10		17a;	2		2			2		2		
H0107	002	0	1	04	01	H0107_002_0	10	5	$275 Copay	01	9a;9b;		2		1	275.00	275.00	2		2		
H0107	002	0	1	04	01	H0107_002_0	10	9	$400 Allowance - Hearing Aids	10		18b;	2		2			2		2		
H0107	002	0	1	04	01	H0107_002_0	10	6	$100 Copay	01	10a;		2		1	100.00	100.00	2		2		
H0107	002	0	1	04	01	H0107_002_0	10	7	$0.00 Copay	11	6;9d;14a;14d;	14c;16a;	2		1	0.00	0.00	2		2		
H0107	002	0	1	04	01	H0107_002_0	10	8	$35 Copay	01	7a;7b;		2		1	35.00	35.00	2		2		
H0107	801	0	1	04	01	H0107_801_0	5	1		01	6;14a;		2		2			2		1	0	0
H0107	801	0	1	04	01	H0107_801_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H0107	802	0	1	04	01	H0107_802_0	5	1		01	6;14a;		2		2			2		1	0	0
H0107	802	0	1	04	01	H0107_802_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H0294	002	0	1	04	01	H0294_002_0	2	1	Group 1	01	3-1;3-2;3-3;7d;16b;		2		1	50.00	50.00	2		2		
H0294	002	0	1	04	01	H0294_002_0	2	9	Group 9	01	8a2;		2		1	18.00	18.00	2		2		
H0294	002	0	1	04	01	H0294_002_0	2	11	Group 11	11	7f;9d;14a;14d;14e;17b;	7f;9d;10b;14c;16b;17b;	2		1	0.00	0.00	2		2		
H0294	002	0	1	04	01	H0294_002_0	2	12	Group 12	10		18b;	2		1	390.00	450.00	2		2		
H0294	002	0	1	04	01	H0294_002_0	2	13	Group 13	01	10a;		2		1	250.00	250.00	2		2		
H0294	002	0	1	04	01	H0294_002_0	2	14	Group 14	01	7g;		2		1	20.00	50.00	2		2		
H0294	002	0	1	04	01	H0294_002_0	2	15	Group 15	01	8b3;		2		1	16.00	16.00	2		2		
H0294	002	0	1	04	01	H0294_002_0	2	2	Group 2	01	6;11a;		2		2			2		1	50	50
H0294	002	0	1	04	01	H0294_002_0	2	3	Group 3	01	5;		2		1	55.00	55.00	2		2		
H0294	002	0	1	04	01	H0294_002_0	2	4	Group 4	11	7a;7b;18a;	16a;18a;	2		1	20.00	20.00	2		2		
H0294	002	0	1	04	01	H0294_002_0	2	5	Group 5	01	17a;		2		1	0.00	50.00	2		2		
H0294	002	0	1	04	01	H0294_002_0	2	6	Group 6	01	7e;7h;9c;		2		1	30.00	40.00	2		2		
H0294	002	0	1	04	01	H0294_002_0	2	8	Group 8	01	8a1;8b1;8b2;9a;9b;11b;11c;12;15;		2		2			2		1	20	20
H0294	002	0	1	04	01	H0294_002_0	2	7	Group 7	10		17a;	2		1	25.00	25.00	2		2		
H0294	002	0	1	04	01	H0294_002_0	2	10	Group 10	01	7c;7i;		2		1	40.00	40.00	2		2		
H0294	004	0	1	04	01	H0294_004_0	2	1	Group 1	11	3-1;3-2;3-3;7d;7f;16b;	7f;	2		1	50.00	50.00	2		2		
H0294	004	0	1	04	01	H0294_004_0	2	10	Group 10	01	7c;7i;		2		1	40.00	40.00	2		2		
H0294	004	0	1	04	01	H0294_004_0	2	11	Group 11	11	9d;14a;14d;14e;17b;	9d;14b;14c;16b;17b;	2		1	0.00	0.00	2		2		
H0294	004	0	1	04	01	H0294_004_0	2	12	Group 12	10		18b;	2		1	390.00	450.00	2		2		
H0294	004	0	1	04	01	H0294_004_0	2	13	Group 13	01	10a;		2		1	250.00	250.00	2		2		
H0294	004	0	1	04	01	H0294_004_0	2	14	Group 14	01	7g;		2		1	20.00	50.00	2		2		
H0294	004	0	1	04	01	H0294_004_0	2	15	Group 15	01	11a;		2		2			2		1	45	45
H0294	004	0	1	04	01	H0294_004_0	2	2	Group 2	01	6;		2		2			2		1	50	50
H0294	004	0	1	04	01	H0294_004_0	2	3	Group 3	01	5;		2		1	55.00	55.00	2		2		
H0294	004	0	1	04	01	H0294_004_0	2	4	Group 4	11	7a;7b;18a;	16a;18a;	2		1	20.00	20.00	2		2		
H0294	004	0	1	04	01	H0294_004_0	2	5	Group 5	01	17a;		2		1	0.00	50.00	2		2		
H0294	004	0	1	04	01	H0294_004_0	2	6	Group 6	01	7e;7h;9c;		2		1	30.00	40.00	2		2		
H0294	004	0	1	04	01	H0294_004_0	2	7	Group 7	10		17a;	2		1	25.00	25.00	2		2		
H0294	004	0	1	04	01	H0294_004_0	2	8	Group 8	01	9a;9b;11b;11c;12;15;		2		2			2		1	20	20
H0294	004	0	1	04	01	H0294_004_0	2	9	Group 9	01	8a1;8a2;8b1;8b2;8b3;		2		1	17.00	20.00	2		1	20	20
H0710	001	0	1	04	01	H0710_001_0	3	5	Group 5	01	14a;		2		2			2		1	0	30
H0710	001	0	1	04	01	H0710_001_0	3	6	Group 6	10		13b;	1	105.00	1	0.00	0.00	2		2		
H0710	001	0	1	04	01	H0710_001_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;	2		2			2		1	30	30
H0710	001	0	1	04	01	H0710_001_0	3	2	Group 2	11	8a2;17b;	16a;16b;17b;	2		1	0.00	0.00	2		2		
H0710	001	0	1	04	01	H0710_001_0	3	3	Group 3	01	10a;12;		2		2			2		1	20	20
H0710	001	0	1	04	01	H0710_001_0	3	4	Group 4	10		10b;	2		2			2		1	75	75
H0710	004	0	1	04	01	H0710_004_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		1	0.00	0.00	2		2		
H0710	004	0	1	04	01	H0710_004_0	4	3	Group 3	10		10b;	2		2			2		1	75	75
H0710	004	0	1	04	01	H0710_004_0	4	4	Group 4	01	14a;		2		2			2		1	0	30
H0710	004	0	1	04	01	H0710_004_0	4	5	Group 5	01	10a;12;		2		2			2		1	20	20
H0710	004	0	1	04	01	H0710_004_0	4	6	Group 6	10		13b;	1	45.00	1	0.00	0.00	2		2		
H0710	004	0	1	04	01	H0710_004_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		2			2		1	30	30
H0710	005	0	1	04	01	H0710_005_0	4	5	Group 5	01	10a;12;		2		2			2		1	20	20
H0710	005	0	1	04	01	H0710_005_0	4	4	Group 4	01	14a;		2		2			2		1	0	30
H0710	005	0	1	04	01	H0710_005_0	4	3	Group 3	10		10b;	2		2			2		1	75	75
H0710	005	0	1	04	01	H0710_005_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		1	0.00	0.00	2		2		
H0710	005	0	1	04	01	H0710_005_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		2			2		1	30	30
H0710	005	0	1	04	01	H0710_005_0	4	6	Group 6	10		13b;	1	110.00	1	0.00	0.00	2		2		
H0710	006	0	1	04	01	H0710_006_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		2			2		1	30	30
H0710	006	0	1	04	01	H0710_006_0	3	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		1	0.00	0.00	2		2		
H0710	006	0	1	04	01	H0710_006_0	3	3	Group 3	10		10b;	2		2			2		1	75	75
H0710	006	0	1	04	01	H0710_006_0	3	4	Group 4	01	14a;		2		2			2		1	0	30
H0710	006	0	1	04	01	H0710_006_0	3	5	Group 5	01	12;		2		2			2		1	20	20
H0710	006	0	1	04	01	H0710_006_0	3	6	Group 6	01	10a;		2		1	100.00	100.00	2		2		
H0710	007	0	1	04	01	H0710_007_0	2	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		2			2		1	30	30
H0710	007	0	1	04	01	H0710_007_0	2	2	Group 2	11	8a2;12;17b;	16a;16b;17b;18b;	2		1	0.00	0.00	2		2		
H0710	007	0	1	04	01	H0710_007_0	2	3	Group 3	10		10b;	2		2			2		1	75	75
H0710	007	0	1	04	01	H0710_007_0	2	4	Group 4	01	14a;		2		2			2		1	0	30
H0710	007	0	1	04	01	H0710_007_0	2	5	Group 5	10		13b;	1	170.00	1	0.00	0.00	2		2		
H0710	007	0	1	04	01	H0710_007_0	2	6	Group 6	01	10a;		2		1	75.00	75.00	2		2		
H0710	008	0	1	04	01	H0710_008_0	3	6	Group 6	10		13b;	1	50.00	1	0.00	0.00	2		2		
H0710	008	0	1	04	01	H0710_008_0	3	5	Group 5	01	12;		2		2			2		1	20	20
H0710	008	0	1	04	01	H0710_008_0	3	4	Group 4	01	14a;		2		2			2		1	0	30
H0710	008	0	1	04	01	H0710_008_0	3	3	Group 3	10		10b;	2		2			2		1	75	75
H0710	008	0	1	04	01	H0710_008_0	3	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		1	0.00	0.00	2		2		
H0710	008	0	1	04	01	H0710_008_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		2			2		1	30	30
H0710	008	0	1	04	01	H0710_008_0	3	7	Group 7	01	10a;		2		1	100.00	100.00	2		2		
H0710	009	0	1	04	01	H0710_009_0	3	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		1	0.00	0.00	2		2		
H0710	009	0	1	04	01	H0710_009_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		2			2		1	30	30
H0710	009	0	1	04	01	H0710_009_0	3	3	Group 3	10		10b;	2		2			2		1	75	75
H0710	009	0	1	04	01	H0710_009_0	3	4	Group 4	01	14a;		2		2			2		1	0	30
H0710	009	0	1	04	01	H0710_009_0	3	5	Group 5	01	12;		2		2			2		1	20	20
H0710	009	0	1	04	01	H0710_009_0	3	6	Group 6	10		13b;	1	50.00	1	0.00	0.00	2		2		
H0710	009	0	1	04	01	H0710_009_0	3	7	Group 7	01	10a;		2		1	100.00	100.00	2		2		
H0710	010	0	1	04	01	H0710_010_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		2			2		1	30	30
H0710	010	0	1	04	01	H0710_010_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		1	0.00	0.00	2		2		
H0710	010	0	1	04	01	H0710_010_0	4	3	Group 3	01	10a;12;		2		2			2		1	20	20
H0710	010	0	1	04	01	H0710_010_0	4	4	Group 4	10		10b;	2		2			2		1	75	75
H0710	010	0	1	04	01	H0710_010_0	4	5	Group 5	01	14a;		2		2			2		1	0	30
H0710	011	0	1	04	01	H0710_011_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		1	0.00	0.00	2		2		
H0710	011	0	1	04	01	H0710_011_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		2			2		1	30	30
H0710	011	0	1	04	01	H0710_011_0	4	3	Group 3	01	10a;12;		2		2			2		1	20	20
H0710	011	0	1	04	01	H0710_011_0	4	5	Group 5	01	14a;		2		2			2		1	0	30
H0710	011	0	1	04	01	H0710_011_0	4	4	Group 4	10		10b;	2		2			2		1	75	75
H0710	012	0	1	04	01	H0710_012_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		2			2		1	30	30
H0710	012	0	1	04	01	H0710_012_0	3	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		1	0.00	0.00	2		2		
H0710	012	0	1	04	01	H0710_012_0	3	3	Group 3	10		10b;	2		2			2		1	75	75
H0710	012	0	1	04	01	H0710_012_0	3	4	Group 4	01	14a;		2		2			2		1	0	30
H0710	012	0	1	04	01	H0710_012_0	3	5	Group 5	01	12;		2		2			2		1	20	20
H0710	012	0	1	04	01	H0710_012_0	3	6	Group 6	10		13b;	1	90.00	1	0.00	0.00	2		2		
H0710	012	0	1	04	01	H0710_012_0	3	7	Group 7	01	10a;		2		1	100.00	100.00	2		2		
H0710	013	0	1	04	01	H0710_013_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		2			2		1	30	30
H0710	013	0	1	04	01	H0710_013_0	4	2	Group 2	11	8a2;17b;	17b;18b;	2		1	0.00	0.00	2		2		
H0710	013	0	1	04	01	H0710_013_0	4	3	Group 3	01	10a;12;		2		2			2		1	20	20
H0710	013	0	1	04	01	H0710_013_0	4	5	Group 5	01	14a;		2		2			2		1	0	30
H0710	013	0	1	04	01	H0710_013_0	4	4	Group 4	10		10b;	2		2			2		1	75	75
H0710	013	0	1	04	01	H0710_013_0	4	6	Group 6	10		13b;	1	90.00	1	0.00	0.00	2		2		
H0710	014	0	1	04	01	H0710_014_0	4	4	Group 4	10		10b;	2		2			2		1	75	75
H0710	014	0	1	04	01	H0710_014_0	4	5	Group 5	01	14a;		2		2			2		1	0	30
H0710	014	0	1	04	01	H0710_014_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;18a;	2		2			2		1	30	30
H0710	014	0	1	04	01	H0710_014_0	4	2	Group 2	11	8a2;17b;	16a;16b;18b;	2		1	0.00	0.00	2		2		
H0710	014	0	1	04	01	H0710_014_0	4	3	Group 3	01	10a;12;		2		2			2		1	20	20
H0710	015	0	1	04	01	H0710_015_0	4	5	Group 5	01	14a;		2		2			2		1	0	30
H0710	015	0	1	04	01	H0710_015_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		2			2		1	30	30
H0710	015	0	1	04	01	H0710_015_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		1	0.00	0.00	2		2		
H0710	015	0	1	04	01	H0710_015_0	4	3	Group 3	01	10a;12;		2		2			2		1	20	20
H0710	015	0	1	04	01	H0710_015_0	4	4	Group 4	10		10b;	2		2			2		1	75	75
H0710	016	0	1	04	01	H0710_016_0	4	5	Group 5	01	14a;		2		2			2		1	0	30
H0710	016	0	1	04	01	H0710_016_0	4	4	Group 4	10		10b;	2		2			2		1	75	75
H0710	016	0	1	04	01	H0710_016_0	4	3	Group 3	01	10a;12;		2		2			2		1	20	20
H0710	016	0	1	04	01	H0710_016_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		1	0.00	0.00	2		2		
H0710	016	0	1	04	01	H0710_016_0	4	6	Group 6	10		13b;	1	45.00	1	0.00	0.00	2		2		
H0710	016	0	1	04	01	H0710_016_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		2			2		1	30	30
H0710	017	0	1	04	01	H0710_017_0	4	4	Group 4	10		10b;	2		2			2		1	75	75
H0710	017	0	1	04	01	H0710_017_0	4	3	Group 3	01	10a;12;		2		2			2		1	20	20
H0710	017	0	1	04	01	H0710_017_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		1	0.00	0.00	2		2		
H0710	017	0	1	04	01	H0710_017_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		2			2		1	30	30
H0710	017	0	1	04	01	H0710_017_0	4	5	Group 5	01	14a;		2		2			2		1	0	30
H0710	017	0	1	04	01	H0710_017_0	4	6	Group 6	10		13b;	1	55.00	1	0.00	0.00	2		2		
H0710	018	0	1	04	01	H0710_018_0	2	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;	2		2			2		1	30	30
H0710	018	0	1	04	01	H0710_018_0	2	2	Group 2	11	8a2;17b;	16a;16b;17b;	2		1	0.00	0.00	2		2		
H0710	018	0	1	04	01	H0710_018_0	2	3	Group 3	10		10b;	2		2			2		1	75	75
H0710	018	0	1	04	01	H0710_018_0	2	4	Group 4	01	14a;		2		2			2		1	0	30
H0710	018	0	1	04	01	H0710_018_0	2	5	Group 5	01	12;		2		2			2		1	20	20
H0710	018	0	1	04	01	H0710_018_0	2	6	Group 6	01	10a;		2		1	100.00	100.00	2		2		
H0710	020	0	1	04	01	H0710_020_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		2			2		1	30	30
H0710	020	0	1	04	01	H0710_020_0	3	6	Group 6	10		13b;	1	45.00	1	0.00	0.00	2		2		
H0710	020	0	1	04	01	H0710_020_0	3	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		1	0.00	0.00	2		2		
H0710	020	0	1	04	01	H0710_020_0	3	3	Group 3	01	10a;12;		2		2			2		1	20	20
H0710	020	0	1	04	01	H0710_020_0	3	4	Group 4	10		10b;	2		2			2		1	75	75
H0710	020	0	1	04	01	H0710_020_0	3	5	Group 5	01	14a;		2		2			2		1	0	30
H0710	801	0	1	04	01	H0710_801_0	1	1		01	6;14a;		2		2			2		1	0	0
H0710	801	0	1	04	01	H0710_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H0735	001	0	1	04	01	H0735_001_0	8	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;17b;18a;	9d;17a;18a;	2		2			2		1	25	25
H0735	001	0	1	04	01	H0735_001_0	8	2	Group 2	11	8a2;12;14a;	14c;16a;	2		2			2		2		
H0735	001	0	1	04	01	H0735_001_0	8	3	Group 3	01	10a;		2		1	200.00	200.00	2		2		
H0735	002	0	1	04	01	H0735_002_0	9	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;17b;18a;	9d;17a;18a;	2		2			2		1	20	20
H0735	002	0	1	04	01	H0735_002_0	9	2	Group 2	11	8a2;12;14a;	14c;16a;	2		2			2		2		
H0735	002	0	1	04	01	H0735_002_0	9	3	Group 3	01	10a;		2		1	100.00	100.00	2		2		
H0840	001	0	1	04	01	H0840_001_0	12	13	Part Hosp & Part B Rx & Prosth & DM	01	5;11a;11b;15;		2		2			2		1	30	30
H0840	001	0	1	04	01	H0840_001_0	12	12	ESRD	01	12;		2		1	35.00	35.00	2		2		
H0840	001	0	1	04	01	H0840_001_0	12	15	Diabetes Education	01	14e;		2		1	40.00	40.00	2		2		
H0840	001	0	1	04	01	H0840_001_0	12	2	Radiology & Lab	01	8a1;8a2;8b1;8b2;8b3;		2		2			2		1	20	20
H0840	001	0	1	04	01	H0840_001_0	12	3	Diabetic Supplies	01	11c;		2		2			2		2		
H0840	001	0	1	04	01	H0840_001_0	12	4	Outpatient Hospital Services	01	3-1;3-2;3-3;9a;9c;9d;		2		2			2		1	20	20
H0840	001	0	1	04	01	H0840_001_0	12	5	Ambulatory Surgical Center	01	9b;		2		1	300.00	300.00	2		2		
H0840	001	0	1	04	01	H0840_001_0	12	6	Home Health Services	01	6;		2		1	35.00	35.00	2		2		
H0840	001	0	1	04	01	H0840_001_0	12	7	Primary Care	01	7a;		2		1	50.00	50.00	2		2		
H0840	001	0	1	04	01	H0840_001_0	12	8	Specialist Services	11	7d;7e;7g;7h;16b;17a;17b;18a;	17a;	2		1	60.00	60.00	2		2		
H0840	001	0	1	04	01	H0840_001_0	12	9	Chiropractic & OT Services	01	7b;7c;7f;7i;		2		1	40.00	40.00	2		2		
H0840	001	0	1	04	01	H0840_001_0	12	14	Preventive	11	14a;	14c;	2		2			2		2		
H0840	001	0	1	04	01	H0840_001_0	12	11	Kidney Disease Education	01	14d;		2		2			2		2		
H0840	001	0	1	04	01	H0840_001_0	12	10	Ambulance	01	10a;		2		1	250.00	250.00	2		2		
H0840	001	0	1	04	01	H0840_001_0	12	1	Vision Hardware	10		17b;	2		2			2		2		
H0840	002	0	1	04	01	H0840_002_0	12	13	Part Hosp & Part B Rx & Prosth & DM	01	5;11a;11b;15;		2		2			2		1	30	30
H0840	002	0	1	04	01	H0840_002_0	12	1	Vision Hardware	10		17b;	2		2			2		2		
H0840	002	0	1	04	01	H0840_002_0	12	15	Diabetes Education	01	14e;		2		1	40.00	40.00	2		2		
H0840	002	0	1	04	01	H0840_002_0	12	2	Radiology & Lab	01	8a1;8a2;8b1;8b2;8b3;		2		2			2		1	20	20
H0840	002	0	1	04	01	H0840_002_0	12	3	Diabetic Supplies	01	11c;		2		2			2		2		
H0840	002	0	1	04	01	H0840_002_0	12	4	Outpatient Hospital Services	01	3-1;3-2;3-3;9a;9c;9d;		2		2			2		1	20	20
H0840	002	0	1	04	01	H0840_002_0	12	5	Ambulatory Surgical Center	01	9b;		2		1	300.00	300.00	2		2		
H0840	002	0	1	04	01	H0840_002_0	12	6	Home Health Services	01	6;		2		1	35.00	35.00	2		2		
H0840	002	0	1	04	01	H0840_002_0	12	7	Primary Care	01	7a;		2		1	50.00	50.00	2		2		
H0840	002	0	1	04	01	H0840_002_0	12	8	Specialist Services	11	7d;7e;7g;7h;16b;17a;17b;18a;	17a;	2		1	60.00	60.00	2		2		
H0840	002	0	1	04	01	H0840_002_0	12	9	Chiropractic & OT Services	01	7b;7c;7f;7i;		2		1	40.00	40.00	2		2		
H0840	002	0	1	04	01	H0840_002_0	12	14	Preventive	11	14a;	14c;	2		2			2		2		
H0840	002	0	1	04	01	H0840_002_0	12	10	Ambulance	01	10a;		2		1	250.00	250.00	2		2		
H0840	002	0	1	04	01	H0840_002_0	12	11	Kidney Disease Education	01	14d;		2		2			2		2		
H0840	002	0	1	04	01	H0840_002_0	12	12	ESRD	01	12;		2		1	35.00	35.00	2		2		
H0879	002	0	1	04	01	H0879_002_0	11	3	Specialist/Healthcare Services	01	7d;7e;7f;7g;7h;9c;17a;18a;		2		1	35.00	35.00	2		2		
H0879	002	0	1	04	01	H0879_002_0	11	1	50% Cost Share	01	3-1;3-2;3-3;5;6;7b;7c;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;11a;11b;12;		2		2			2		1	50	50
H0879	002	0	1	04	01	H0879_002_0	11	5	Diabetes/Kidney Disease	01	14a;14d;14e;		2		1	0.00	0.00	2		2		
H0879	002	0	1	04	01	H0879_002_0	11	6	Part B Drugs	01	9d;15;		2		2			2		1	30	30
H0879	002	0	1	04	01	H0879_002_0	11	7	OP Blood Services	10		9d;	2		2			2		1	30	30
H0879	002	0	1	04	01	H0879_002_0	11	8	Diabetic Supplies	01	11c;		2		2			2		1	20	20
H0879	002	0	1	04	01	H0879_002_0	11	9	Comprehensive Dental	01	16b;17b;		2		2			2		2		
H0879	002	0	1	04	01	H0879_002_0	11	4	Ambulance	01	10a;		2		1	295.00	295.00	2		2		
H0879	002	0	1	04	01	H0879_002_0	11	10	Supplemental	10		10b;13c;14c;	2		1	0.00	0.00	2		2		
H0879	002	0	1	04	01	H0879_002_0	11	11		10		16a;17b;	2		2			2		2		
H0879	002	0	1	04	01	H0879_002_0	11	2	PCP	01	7a;		2		1	50.00	50.00	2		2		
H0879	004	0	1	04	01	H0879_004_0	8	3	Specialist/Healthcare Services	01	7d;7e;7f;7g;7h;9c;17a;18a;		2		1	35.00	35.00	2		2		
H0879	004	0	1	04	01	H0879_004_0	8	4	Ambulance	01	10a;		2		1	275.00	275.00	2		2		
H0879	004	0	1	04	01	H0879_004_0	8	5	Diabetes/Kidney Disease	01	14d;14e;		2		2			2		2		
H0879	004	0	1	04	01	H0879_004_0	8	6	Part B Drugs	01	15;		2		2			2		1	30	30
H0879	004	0	1	04	01	H0879_004_0	8	7	OP Blood	11	9d;	9d;	2		2			2		1	30	30
H0879	004	0	1	04	01	H0879_004_0	8	1	50% Cost Share	01	3-1;3-2;3-3;5;6;7b;7c;7i;9a;9b;11a;11b;12;		2		2			2		1	50	50
H0879	004	0	1	04	01	H0879_004_0	8	9	OON Dental	01	8a1;8a2;8b1;8b2;8b3;		2		2			2		1	50	50
H0879	004	0	1	04	01	H0879_004_0	8	2	PCP	01	7a;		2		1	35.00	35.00	2		2		
H0879	004	0	1	04	01	H0879_004_0	8	11	Diabetic Supplies	01	11c;		2		2			2		1	20	20
H0879	004	0	1	04	01	H0879_004_0	8	10	Suplimental	11	14a;16b;17b;	10b;13c;14c;	2		2			2		2		
H0879	004	0	1	04	01	H0879_004_0	8	8	Other	10		16a;17b;	2		2			2		2		
H1291	001	0	1	09	04	H1291_001_0	3	1		11	6;9d;14a;14d;14e;17b;	9d;13d;14b;17a;	2		1	0.00	0.00	2		2		
H1291	001	0	1	09	04	H1291_001_0	3	9		01	9a;				1	354.00	354.00	2		2		
H1291	001	0	1	09	04	H1291_001_0	3	11		01	7c;7e;7h;7i;				1	40.00	40.00	2		2		
H1291	001	0	1	09	04	H1291_001_0	3	12		01	3-1;3-2;3-3;5;7d;7f;7g;16b;18a;				1	50.00	50.00	2		2		
H1291	001	0	1	09	04	H1291_001_0	3	13		01	8b2;11a;11b;11c;12;15;				2			2		1	20	20
H1291	001	0	1	09	04	H1291_001_0	3	14		10		13c;14c;16a;16b;	2		2			2		1	50	50
H1291	001	0	1	09	04	H1291_001_0	3	15		10		13b;	1	25.00	2			2		1	50	50
H1291	001	0	1	09	04	H1291_001_0	3	2		01	8a1;				1	0.00	100.00	2		2		
H1291	001	0	1	09	04	H1291_001_0	3	3		01	8a2;17a;				1	0.00	50.00	2		2		
H1291	001	0	1	09	04	H1291_001_0	3	4		01	8b3;				1	15.00	100.00	2		2		
H1291	001	0	1	09	04	H1291_001_0	3	5		01	7a;7b;				1	15.00	15.00	2		2		
H1291	001	0	1	09	04	H1291_001_0	3	6		01	8b1;				1	15.00	354.00	2		2		
H1291	001	0	1	09	04	H1291_001_0	3	7		01	10a;				1	300.00	300.00	2		2		
H1291	001	0	1	09	04	H1291_001_0	3	8		01	9b;				1	304.00	304.00	2		2		
H1291	001	0	1	09	04	H1291_001_0	3	10		01	9c;				1	40.00	100.00	2		2		
H1302	004	0	1	04	01	H1302_004_0	2	5	20% Coinsurance	01	6;9a;9b;11a;11b;11c;12;		2		2			2		1	20	20
H1302	004	0	1	04	01	H1302_004_0	2	4	30% Coinsurance	01	15;		2		2			2		1	30	30
H1302	004	0	1	04	01	H1302_004_0	2	3	Ambulance $175 Copayment	01	10a;		2		1	175.00	175.00	2		2		
H1302	004	0	1	04	01	H1302_004_0	2	2	$30 Copay	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;17a;18a;	17a;	2		1	30.00	30.00	2		2		
H1302	004	0	1	04	01	H1302_004_0	2	1	No Cost Share	01	14a;14d;14e;17b;		2		2			2		2		
H1302	004	0	1	04	01	H1302_004_0	2	6	25% Coinsurance	11	5;7e;7h;8a1;8a2;8b1;8b2;8b3;9c;9d;16b;	9d;	2		2			2		1	25	25
H1302	004	0	1	04	01	H1302_004_0	2	7	$100 Vision Eyewear Maximum	10		17b;	2		2			2		2		
H1302	004	0	1	04	01	H1302_004_0	2	8	$0 to $10 Copayment	10		14c;	2		1	0.00	10.00	2		2		
H1302	007	1	1	04	01	H1302_007_1	5	5	$100 Vision Hardware Maximum	10		17b;	2		2			2		2		
H1302	007	1	1	04	01	H1302_007_1	5	4	$0 to $10 Copayment	10		14c;	2		1	0.00	10.00	2		2		
H1302	007	1	1	04	01	H1302_007_1	5	3	30% Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;15;16b;17a;	9d;17a;	2		2			2		1	30	30
H1302	007	1	1	04	01	H1302_007_1	5	2	$45.00 Copay	01	7d;7f;7g;18a;		2		1	45.00	45.00	2		2		
H1302	007	1	1	04	01	H1302_007_1	5	1	No Cost Share	01	14a;14d;14e;17b;		2		2			2		2		
H1302	007	1	1	04	01	H1302_007_1	5	6	Ambulance $200 Copayment	01	10a;		2		1	200.00	200.00	2		2		
H1302	007	1	1	04	01	H1302_007_1	5	7	$25 Copay	01	7a;		2		1	25.00	25.00	2		2		
H1302	007	2	1	04	01	H1302_007_2	5	1	No Cost Share	01	14a;14d;14e;17b;		2		2			2		2		
H1302	007	2	1	04	01	H1302_007_2	5	2	$45.00 Copay	01	7d;7f;7g;18a;		2		1	45.00	45.00	2		2		
H1302	007	2	1	04	01	H1302_007_2	5	3	30% Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;15;16b;17a;	9d;17a;	2		2			2		1	30	30
H1302	007	2	1	04	01	H1302_007_2	5	4	$0 to $10 Copayment	10		14c;	2		1	0.00	10.00	2		2		
H1302	007	2	1	04	01	H1302_007_2	5	5	$100 Vision Hardware Maximum	10		17b;	2		2			2		2		
H1302	007	2	1	04	01	H1302_007_2	5	6	Ambulance $200 Copayment	01	10a;		2		1	200.00	200.00	2		2		
H1302	007	2	1	04	01	H1302_007_2	5	7	$25 Copay	01	7a;		2		1	25.00	25.00	2		2		
H1304	001	0	1	04	01	H1304_001_0	5	1	$0 copay	10		14c;17b;	2		2			2		2		
H1304	001	0	1	04	01	H1304_001_0	5	2	$40 copay	10		17a;	2		1	40.00	40.00	2		2		
H1304	001	0	1	04	01	H1304_001_0	5	3	$300 copay	01	10a;		2		1	300.00	300.00	2		2		
H1304	001	0	1	04	01	H1304_001_0	5	4	30% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;	2		2			2		1	30	30
H1304	001	0	1	04	01	H1304_001_0	5	5	50% coinsurance	10		16a;	2		2			2		1	50	50
H1304	002	0	1	04	01	H1304_002_0	7	1	$0 copay	10		14c;17b;	2		2			2		2		
H1304	002	0	1	04	01	H1304_002_0	7	2	$35 copay	10		17a;	2		1	35.00	35.00	2		2		
H1304	002	0	1	04	01	H1304_002_0	7	3	$300 copay	01	10a;		2		1	300.00	300.00	2		2		
H1304	002	0	1	04	01	H1304_002_0	7	4	30% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;	2		2			2		1	30	30
H1304	002	0	1	04	01	H1304_002_0	7	5	50% coinsurance	10		16a;	2		2			2		1	50	50
H1304	004	0	1	04	01	H1304_004_0	6	1	$0 copay	10		14c;17b;	2		2			2		2		
H1304	004	0	1	04	01	H1304_004_0	6	2	$30 copay	10		17a;	2		1	30.00	30.00	2		2		
H1304	004	0	1	04	01	H1304_004_0	6	3	$250 copay	01	10a;		2		1	250.00	250.00	2		2		
H1304	004	0	1	04	01	H1304_004_0	6	4	30% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;	2		2			2		1	30	30
H1304	004	0	1	04	01	H1304_004_0	6	5	50% coinsurance	10		16a;	2		2			2		1	50	50
H1304	004	0	1	04	01	H1304_004_0	6	6	$599 or $899 copay	10		18b;	2		1	599.00	899.00	2		2		
H1304	008	0	1	04	01	H1304_008_0	5	1	$0 copay	10		14c;17b;	2		2			2		2		
H1304	008	0	1	04	01	H1304_008_0	5	2	$40 copay	10		17a;	2		1	40.00	40.00	2		2		
H1304	008	0	1	04	01	H1304_008_0	5	3	$300 copay	01	10a;		2		1	300.00	300.00	2		2		
H1304	008	0	1	04	01	H1304_008_0	5	4	30% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;	2		2			2		1	30	30
H1304	008	0	1	04	01	H1304_008_0	5	5	50% coinsurance	10		16a;	2		2			2		1	50	50
H1304	009	0	1	04	01	H1304_009_0	7	1	$0 copay	10		14c;17b;	2		2			2		2		
H1304	009	0	1	04	01	H1304_009_0	7	2	$40 copay	10		17a;	2		1	40.00	40.00	2		2		
H1304	009	0	1	04	01	H1304_009_0	7	5	50% coinsurance	10		16a;	2		2			2		1	50	50
H1304	009	0	1	04	01	H1304_009_0	7	4	30% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;	2		2			2		1	30	30
H1304	009	0	1	04	01	H1304_009_0	7	3	$300 copay	01	10a;		2		1	300.00	300.00	2		2		
H1304	010	0	1	04	01	H1304_010_0	7	1	$0 copay	10		14c;17b;	2		2			2		2		
H1304	010	0	1	04	01	H1304_010_0	7	2	$30 copay	10		17a;	2		1	30.00	30.00	2		2		
H1304	010	0	1	04	01	H1304_010_0	7	3	$250 copay	01	10a;		2		1	250.00	250.00	2		2		
H1304	010	0	1	04	01	H1304_010_0	7	4	30% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;	2		2			2		1	30	30
H1304	010	0	1	04	01	H1304_010_0	7	5	50% coinsurance	10		16a;	2		2			2		1	50	50
H1304	010	0	1	04	01	H1304_010_0	7	6	$599 or $899 copay	10		18b;	2		1	599.00	899.00	2		2		
H1304	803	0	1	04	01	H1304_803_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1304	803	0	1	04	01	H1304_803_0	6	1		01	6;14a;		2		2			2		1	0	0
H1304	804	0	1	04	01	H1304_804_0	7	1		01	6;14a;		2		2			2		1	0	0
H1304	804	0	1	04	01	H1304_804_0	7	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1365	001	0	1	04	01	H1365_001_0	10	1	1	11	3-1;3-2;3-3;5;7b;7c;7d;7e;7f;7g;7h;7i;8b1;8b2;9a;9b;9c;9d;11a;11b;14a;16b;17a;17b;18a;	14b;17a;	2		2			2		1	30	30
H1365	001	0	1	04	01	H1365_001_0	10	8	8	01	8b3;		2		1	15.00	15.00	2		2		
H1365	001	0	1	04	01	H1365_001_0	10	7	7	01	7a;		2		1	25.00	25.00	2		2		
H1365	001	0	1	04	01	H1365_001_0	10	6	6	01	10a;		2		1	200.00	200.00	2		2		
H1365	001	0	1	04	01	H1365_001_0	10	5	5	11	14d;14e;	14c;	2		2			2		2		
H1365	001	0	1	04	01	H1365_001_0	10	4	4	01	8a2;		2		2			2		1	0	20
H1365	001	0	1	04	01	H1365_001_0	10	3	3	01	8a1;		2		2			2		1	0	15
H1365	001	0	1	04	01	H1365_001_0	10	2	2	01	6;11c;12;15;		2		2			2		1	20	20
H1365	002	0	1	04	01	H1365_002_0	10	1	1	11	3-1;3-2;3-3;5;7b;7c;7d;7e;7f;7g;7h;7i;8b1;8b2;9a;9b;9c;9d;11a;11b;14a;16b;17a;17b;18a;	14b;17a;	2		2			2		1	30	30
H1365	002	0	1	04	01	H1365_002_0	10	2	2	01	6;11c;12;15;		2		2			2		1	20	20
H1365	002	0	1	04	01	H1365_002_0	10	3	3	01	8a1;		2		2			2		1	0	15
H1365	002	0	1	04	01	H1365_002_0	10	4	4	01	8a2;		2		2			2		1	0	20
H1365	002	0	1	04	01	H1365_002_0	10	5	5	11	14d;14e;	14c;	2		2			2		2		
H1365	002	0	1	04	01	H1365_002_0	10	6	6	01	10a;		2		1	200.00	200.00	2		2		
H1365	002	0	1	04	01	H1365_002_0	10	7	7	01	7a;		2		1	25.00	25.00	2		2		
H1365	002	0	1	04	01	H1365_002_0	10	8	8	01	8b3;		2		1	15.00	15.00	2		2		
H1365	003	0	1	04	01	H1365_003_0	12	1	1	11	3-1;3-2;3-3;5;7b;7c;7d;7e;7f;7g;7h;7i;8b1;8b2;9a;9b;9c;9d;11a;11b;14a;16b;17a;17b;18a;	14b;17a;	2		2			2		1	30	30
H1365	003	0	1	04	01	H1365_003_0	12	2	2	01	6;11c;12;15;		2		2			2		1	20	20
H1365	003	0	1	04	01	H1365_003_0	12	5	5	11	14d;14e;	14c;	2		2			2		2		
H1365	003	0	1	04	01	H1365_003_0	12	6	6	01	10a;		2		1	200.00	200.00	2		2		
H1365	003	0	1	04	01	H1365_003_0	12	7	7	01	7a;		2		1	25.00	25.00	2		2		
H1365	003	0	1	04	01	H1365_003_0	12	3	3	01	8a1;		2		2			2		1	0	15
H1365	003	0	1	04	01	H1365_003_0	12	4	4	01	8a2;		2		2			2		1	0	20
H1365	003	0	1	04	01	H1365_003_0	12	8	8	01	8b3;		2		1	15.00	15.00	2		2		
H1365	802	0	1	04	01	H1365_802_0	7	1		01	6;14a;		2		2			2		1	0	0
H1365	802	0	1	04	01	H1365_802_0	7	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1365	803	0	1	04	01	H1365_803_0	7	1		01	6;14a;		2		2			2		1	0	0
H1365	803	0	1	04	01	H1365_803_0	7	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1417	001	0	1	04	01	H1417_001_0	3	1	Office Visits	11	3-1;3-2;3-3;5;6;7a;7c;7i;8a1;8a2;8b1;8b2;8b3;14a;14d;14e;16b;17a;18a;	14b;14c;	2		1	30.00	30.00	2		2		
H1417	001	0	1	04	01	H1417_001_0	3	2	Renal Dialysis	11	9d;12;	9d;	2		2			2		2		
H1417	001	0	1	04	01	H1417_001_0	3	8	Part B Drugs	01	15;		2		2			2		1	20	20
H1417	001	0	1	04	01	H1417_001_0	3	7	Specialty Visits	01	7b;7d;7e;7f;7g;7h;9c;		2		1	40.00	40.00	2		2		
H1417	001	0	1	04	01	H1417_001_0	3	6	Dental, Vision, and Hearing	11	17b;	16a;16b;17a;17b;18a;18b;	2		2			2		2		
H1417	001	0	1	04	01	H1417_001_0	3	5	ASC	01	9a;9b;		2		1	200.00	200.00	2		2		
H1417	001	0	1	04	01	H1417_001_0	3	4	DME	01	11a;11b;11c;		2		2			2		1	20	20
H1417	001	0	1	04	01	H1417_001_0	3	3	Ambulance	01	10a;		2		1	100.00	100.00	2		2		
H1417	002	0	1	04	01	H1417_002_0	4	1	Office Visits	11	3-1;3-2;3-3;5;6;7a;7c;7i;8a1;8a2;8b1;8b2;8b3;14a;14d;14e;16b;17a;18a;	14b;14c;	2		1	30.00	30.00	2		2		
H1417	002	0	1	04	01	H1417_002_0	4	7	Specialty Visits	01	7b;7d;7e;7f;7g;7h;9c;		2		1	40.00	40.00	2		2		
H1417	002	0	1	04	01	H1417_002_0	4	6	Dental, Vision, and Hearing	11	17b;	16a;16b;17a;17b;18a;18b;	2		2			2		2		
H1417	002	0	1	04	01	H1417_002_0	4	5	ASC	01	9a;9b;		2		1	200.00	200.00	2		2		
H1417	002	0	1	04	01	H1417_002_0	4	4	DME	01	11a;11b;11c;		2		2			2		1	20	20
H1417	002	0	1	04	01	H1417_002_0	4	3	Ambulance	01	10a;		2		1	100.00	100.00	2		2		
H1417	002	0	1	04	01	H1417_002_0	4	2	Renal Dialysis	11	9d;12;	9d;	2		2			2		2		
H1417	002	0	1	04	01	H1417_002_0	4	8	Part B Drugs	01	15;		2		2			2		1	20	20
H1417	003	0	1	04	01	H1417_003_0	3	3	Ambulance	01	10a;		2		1	100.00	100.00	2		2		
H1417	003	0	1	04	01	H1417_003_0	3	4	DME	01	11a;11b;11c;		2		2			2		1	20	20
H1417	003	0	1	04	01	H1417_003_0	3	5	ASC	01	9a;9b;		2		1	200.00	200.00	2		2		
H1417	003	0	1	04	01	H1417_003_0	3	6	Dental, Vision, and Hearing	11	17b;	16a;16b;17a;17b;18a;18b;	2		2			2		2		
H1417	003	0	1	04	01	H1417_003_0	3	7	Part B Drugs	01	15;		2		2			2		1	20	20
H1417	003	0	1	04	01	H1417_003_0	3	1	Office Visits	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9c;14a;14d;14e;16b;17a;18a;	14b;14c;	2		1	50.00	50.00	2		2		
H1417	003	0	1	04	01	H1417_003_0	3	2	Renal Dialysis	11	9d;12;	9d;	2		2			2		2		
H1417	004	0	1	04	01	H1417_004_0	4	4	DME	01	11a;11b;11c;		2		2			2		1	20	20
H1417	004	0	1	04	01	H1417_004_0	4	3	Ambulance	01	10a;		2		1	100.00	100.00	2		2		
H1417	004	0	1	04	01	H1417_004_0	4	2	Renal Dialysis	11	9d;12;	9d;	2		2			2		2		
H1417	004	0	1	04	01	H1417_004_0	4	1	Office Visits	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9c;14a;14d;14e;16b;17a;18a;	14b;14c;	2		1	50.00	50.00	2		2		
H1417	004	0	1	04	01	H1417_004_0	4	5	ASC	01	9a;9b;		2		1	200.00	200.00	2		2		
H1417	004	0	1	04	01	H1417_004_0	4	6	Dental, Vision, and Hearing	11	17b;	16a;16b;17a;17b;18a;18b;	2		2			2		2		
H1417	004	0	1	04	01	H1417_004_0	4	7	Part B Drugs	01	15;		2		2			2		1	20	20
H1417	010	0	1	04	01	H1417_010_0	4	4	DME	01	11a;11b;11c;		2		2			2		1	20	20
H1417	010	0	1	04	01	H1417_010_0	4	3	Ambulance	01	10a;		2		1	100.00	100.00	2		2		
H1417	010	0	1	04	01	H1417_010_0	4	2	Renal Dialysis	11	9d;12;	9d;	2		2			2		2		
H1417	010	0	1	04	01	H1417_010_0	4	1	Office Visits	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9c;14a;14d;14e;16b;17a;18a;	14b;14c;	2		1	50.00	50.00	2		2		
H1417	010	0	1	04	01	H1417_010_0	4	5	ASC	01	9a;9b;		2		2			2		1	20	20
H1417	010	0	1	04	01	H1417_010_0	4	8	Part B Drugs	01	15;		2		2			2		1	20	20
H1417	010	0	1	04	01	H1417_010_0	4	7	Partial Hospitalization	01	5;		2		1	55.00	55.00	2		2		
H1417	010	0	1	04	01	H1417_010_0	4	6	Dental, Vision, and Hearing	11	17b;	16a;16b;17a;17b;18a;18b;	2		2			2		2		
H1417	011	0	1	04	01	H1417_011_0	3	1	Office Visits	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9c;14a;14d;14e;16b;17a;18a;	14b;14c;	2		1	50.00	50.00	2		2		
H1417	011	0	1	04	01	H1417_011_0	3	2	Renal Dialysis	11	9d;12;	9d;	2		2			2		2		
H1417	011	0	1	04	01	H1417_011_0	3	3	Ambulance	01	10a;		2		1	100.00	100.00	2		2		
H1417	011	0	1	04	01	H1417_011_0	3	4	DME	01	11a;11b;11c;		2		2			2		1	20	20
H1417	011	0	1	04	01	H1417_011_0	3	7	Partial Hospitalization	01	5;		2		1	55.00	55.00	2		2		
H1417	011	0	1	04	01	H1417_011_0	3	6	Dental, Vision, and Hearing	11	17b;	16a;16b;17a;17b;18a;18b;	2		2			2		2		
H1417	011	0	1	04	01	H1417_011_0	3	5	ASC	01	9a;9b;		2		2			2		1	20	20
H1417	011	0	1	04	01	H1417_011_0	3	8	Part B Drugs	01	15;		2		2			2		1	20	20
H1417	801	0	1	04	01	H1417_801_0	2	1		01	6;14a;		2		2			2		1	0	0
H1417	801	0	1	04	01	H1417_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1417	802	0	1	04	01	H1417_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1417	802	0	1	04	01	H1417_802_0	2	1		01	6;14a;		2		2			2		1	0	0
H1417	810	0	1	04	01	H1417_810_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1417	810	0	1	04	01	H1417_810_0	2	1		01	6;14a;		2		2			2		1	0	0
H1418	002	0	1	04	01	H1418_002_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;15;16b;17a;18a;	13c;13d;14b;14c;16a;16b;	2		2			2		1	50	50
H1418	002	0	1	04	01	H1418_002_0	3	4		01	12;		2		2			2		1	20	20
H1418	002	0	1	04	01	H1418_002_0	3	3		01	14a;		2		2			2		1	0	50
H1418	002	0	1	04	01	H1418_002_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H1418	002	0	1	04	01	H1418_002_0	3	6		10		13b;	1	25.00	2			2		1	50	50
H1418	002	0	1	04	01	H1418_002_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H1418	007	0	1	04	01	H1418_007_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H1418	007	0	1	04	01	H1418_007_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H1418	007	0	1	04	01	H1418_007_0	3	3		10		18a;	2		1	35.00	35.00	2		2		
H1418	007	0	1	04	01	H1418_007_0	3	8		10		13b;	1	25.00	2			2		1	50	50
H1418	007	0	1	04	01	H1418_007_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	7f;13c;13d;14b;14c;16a;16b;	2		2			2		1	50	50
H1418	007	0	1	04	01	H1418_007_0	3	6		01	11a;		2		2			2		1	45	45
H1418	007	0	1	04	01	H1418_007_0	3	5		01	12;		2		2			2		1	20	20
H1418	007	0	1	04	01	H1418_007_0	3	4		01	14a;		2		2			2		1	0	50
H1418	008	0	1	04	01	H1418_008_0	3	1		11	9d;	9d;	2		1	0.00	0.00	2		2		
H1418	008	0	1	04	01	H1418_008_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11c;14d;14e;15;16b;17a;17b;18a;	13c;13d;14b;14c;	2		2			2		1	50	50
H1418	008	0	1	04	01	H1418_008_0	3	5		01	11a;11b;		2		2			2		1	30	30
H1418	008	0	1	04	01	H1418_008_0	3	4		01	12;		2		2			2		1	20	20
H1418	008	0	1	04	01	H1418_008_0	3	3		01	14a;		2		2			2		1	0	50
H1418	008	0	1	04	01	H1418_008_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H1418	008	0	1	04	01	H1418_008_0	3	7		10		13b;	1	10.00	2			2		1	50	50
H1510	001	0	1	04	01	H1510_001_0	3	10		10		16b;	2		2			2		1	50	80
H1510	001	0	1	04	01	H1510_001_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H1510	001	0	1	04	01	H1510_001_0	3	9		10		13b;	1	15.00	2			2		1	50	50
H1510	001	0	1	04	01	H1510_001_0	3	8		10		13c;14c;16a;	2		2			2		1	50	50
H1510	001	0	1	04	01	H1510_001_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H1510	001	0	1	04	01	H1510_001_0	3	6		01	15;		2		2			2		1	20	30
H1510	001	0	1	04	01	H1510_001_0	3	5		01	11a;		2		2			2		1	20	20
H1510	001	0	1	04	01	H1510_001_0	3	4		01	14a;		2		2			2		1	0	30
H1510	001	0	1	04	01	H1510_001_0	3	3		01	12;		2		2			2		1	0	20
H1510	001	0	1	04	01	H1510_001_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H1510	004	0	1	04	01	H1510_004_0	3	8		10		13c;14c;16a;16b;	2		2			2		1	50	50
H1510	004	0	1	04	01	H1510_004_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H1510	004	0	1	04	01	H1510_004_0	3	6		01	15;		2		2			2		1	20	30
H1510	004	0	1	04	01	H1510_004_0	3	5		01	11a;		2		2			2		1	20	20
H1510	004	0	1	04	01	H1510_004_0	3	9		10		13b;	1	15.00	2			2		1	50	50
H1510	004	0	1	04	01	H1510_004_0	3	3		01	12;		2		2			2		1	0	20
H1510	004	0	1	04	01	H1510_004_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H1510	004	0	1	04	01	H1510_004_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H1510	004	0	1	04	01	H1510_004_0	3	4		01	14a;		2		2			2		1	0	30
H1510	005	0	1	04	01	H1510_005_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H1510	005	0	1	04	01	H1510_005_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H1510	005	0	1	04	01	H1510_005_0	3	3		01	12;		2		2			2		1	0	20
H1510	005	0	1	04	01	H1510_005_0	3	9		10		13b;	1	15.00	2			2		1	50	50
H1510	005	0	1	04	01	H1510_005_0	3	8		10		13c;14c;16a;16b;	2		2			2		1	50	50
H1510	005	0	1	04	01	H1510_005_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H1510	005	0	1	04	01	H1510_005_0	3	6		01	11a;		2		2			2		1	23	23
H1510	005	0	1	04	01	H1510_005_0	3	5		01	15;		2		2			2		1	20	30
H1510	005	0	1	04	01	H1510_005_0	3	4		01	14a;		2		2			2		1	0	30
H1517	007	0	1	04	01	H1517_007_0	10	1	$0	11	9d;16b;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H1517	007	0	1	04	01	H1517_007_0	10	2	20%	11	8b2;12;	16a;18a;	2		2			2		1	20	20
H1517	007	0	1	04	01	H1517_007_0	10	9	Eligible Supplemental Benefits	10		14c;	1	95.00	1	0.00	0.00	2		2		
H1517	007	0	1	04	01	H1517_007_0	10	8	$30	01	8a2;		2		1	30.00	30.00	2		2		
H1517	007	0	1	04	01	H1517_007_0	10	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;		2		2			2		1	40	40
H1517	007	0	1	04	01	H1517_007_0	10	6	SPEC	11	7b;7c;7d;7e;7f;7h;7i;	14b;	2		1	60.00	60.00	2		2		
H1517	007	0	1	04	01	H1517_007_0	10	5	PCP	01	7a;7g;		2		1	40.00	40.00	2		2		
H1517	007	0	1	04	01	H1517_007_0	10	3	Ambulance	01	10a;		2		1	250.00	250.00	2		1	20	20
H1517	007	0	1	04	01	H1517_007_0	10	4	Diag/Rad	01	8a1;8b1;8b3;		2		2			2		1	35	35
H1517	801	0	1	04	01	H1517_801_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1517	801	0	1	04	01	H1517_801_0	4	1		01	6;14a;		2		2			2		1	0	0
H1517	802	0	1	04	01	H1517_802_0	4	1		01	6;14a;		2		2			2		1	0	0
H1517	802	0	1	04	01	H1517_802_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1517	803	0	1	04	01	H1517_803_0	4	1		01	6;14a;		2		2			2		1	0	0
H1517	803	0	1	04	01	H1517_803_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1537	001	0	1	04	01	H1537_001_0	3	1	Group 1	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8b1;8b2;8b3;9a;9b;11b;11c;14d;14e;15;16b;17a;17b;18a;	7f;14b;17a;18a;	2		2			2		1	40	40
H1537	001	0	1	04	01	H1537_001_0	3	2	Group 2	11	9d;	9d;14c;	2		1	0.00	0.00	2		2		
H1537	001	0	1	04	01	H1537_001_0	3	9	Group 9	01	5;		2		1	75.00	75.00	2		2		
H1537	001	0	1	04	01	H1537_001_0	3	8	Group 8	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
H1537	001	0	1	04	01	H1537_001_0	3	7	Group 7	01	8a2;		2		1	16.00	16.00	2		2		
H1537	001	0	1	04	01	H1537_001_0	3	6	Group 6	01	14a;		2		2			2		1	0	40
H1537	001	0	1	04	01	H1537_001_0	3	5	Group 5	01	10a;		2		1	250.00	250.00	2		2		
H1537	001	0	1	04	01	H1537_001_0	3	3	Group 3	01	6;11a;		2		2			2		1	50	50
H1537	001	0	1	04	01	H1537_001_0	3	4	Group 4	01	12;		2		2			2		1	20	20
H1537	801	0	1	04	01	H1537_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1537	801	0	1	04	01	H1537_801_0	1	1		01	6;14a;		2		2			2		1	0	0
H1537	802	0	1	04	01	H1537_802_0	1	1		01	6;14a;		2		2			2		1	0	0
H1537	802	0	1	04	01	H1537_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1537	803	0	1	04	01	H1537_803_0	1	1		01	6;14a;		2		2			2		1	0	0
H1537	803	0	1	04	01	H1537_803_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1537	804	0	2	04	01	H1537_804_0	1	1		01	6;14a;		2		2			2		1	0	0
H1537	804	0	2	04	01	H1537_804_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1537	805	0	2	04	01	H1537_805_0	1	1		01	6;14a;		2		2			2		1	0	0
H1537	805	0	2	04	01	H1537_805_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1537	806	0	2	04	01	H1537_806_0	1	1		01	6;14a;		2		2			2		1	0	0
H1537	806	0	2	04	01	H1537_806_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1537	807	0	1	04	01	H1537_807_0	1	1		01	6;14a;		2		2			2		1	0	0
H1537	807	0	1	04	01	H1537_807_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1537	808	0	1	04	01	H1537_808_0	1	1		01	6;14a;		2		2			2		1	0	0
H1537	808	0	1	04	01	H1537_808_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1537	809	0	1	04	01	H1537_809_0	1	1		01	6;14a;		2		2			2		1	0	0
H1537	809	0	1	04	01	H1537_809_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1537	816	0	1	04	01	H1537_816_0	1	1		01	6;14a;		2		2			2		1	0	0
H1537	816	0	1	04	01	H1537_816_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1537	817	0	1	04	01	H1537_817_0	1	1		01	6;14a;		2		2			2		1	0	0
H1537	817	0	1	04	01	H1537_817_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1537	823	0	1	04	01	H1537_823_0	1	1		01	6;14a;		2		2			2		1	0	0
H1537	823	0	1	04	01	H1537_823_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1537	824	0	1	04	01	H1537_824_0	1	1		01	6;14a;		2		2			2		1	0	0
H1537	824	0	1	04	01	H1537_824_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1537	825	0	1	04	01	H1537_825_0	1	1		01	6;14a;		2		2			2		1	0	0
H1537	825	0	1	04	01	H1537_825_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1537	826	0	1	04	01	H1537_826_0	1	1		01	6;14a;		2		2			2		1	0	0
H1537	826	0	1	04	01	H1537_826_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1537	827	0	2	04	01	H1537_827_0	1	1		01	6;14a;		2		2			2		1	0	0
H1537	827	0	2	04	01	H1537_827_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1537	828	0	2	04	01	H1537_828_0	1	1		01	6;14a;		2		2			2		1	0	0
H1537	828	0	2	04	01	H1537_828_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1537	829	0	2	04	01	H1537_829_0	1	1		01	6;14a;		2		2			2		1	0	0
H1537	829	0	2	04	01	H1537_829_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1607	012	0	1	04	01	H1607_012_0	9	1	$0	11	9d;16b;17b;	9d;14c;17a;	2		1	0.00	0.00	2		2		
H1607	012	0	1	04	01	H1607_012_0	9	2	20%	11	8b2;12;15;	16a;18a;	2		2			2		1	20	20
H1607	012	0	1	04	01	H1607_012_0	9	3	Ambulance	01	10a;		2		1	250.00	250.00	2		1	20	20
H1607	012	0	1	04	01	H1607_012_0	9	4	Diag/Rad	01	8a1;8b1;8b3;		2		2			2		1	30	30
H1607	012	0	1	04	01	H1607_012_0	9	5	PCP	01	7a;7g;		2		1	40.00	40.00	2		2		
H1607	012	0	1	04	01	H1607_012_0	9	6	SPEC	11	7b;7c;7d;7e;7f;7h;7i;	14b;	2		1	60.00	60.00	2		2		
H1607	012	0	1	04	01	H1607_012_0	9	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;17a;18a;		2		2			2		1	40	40
H1607	012	0	1	04	01	H1607_012_0	9	8	$25	01	8a2;		2		1	25.00	25.00	2		2		
H1607	804	0	1	04	01	H1607_804_0	4	1		01	6;14a;		2		2			2		1	0	0
H1607	804	0	1	04	01	H1607_804_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1607	805	0	1	04	01	H1607_805_0	4	1		01	6;14a;		2		2			2		1	0	0
H1607	805	0	1	04	01	H1607_805_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1607	806	0	1	04	01	H1607_806_0	4	1		01	6;14a;		2		2			2		1	0	0
H1607	806	0	1	04	01	H1607_806_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1608	001	0	1	04	01	H1608_001_0	5	1	40% OON	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;	2		2			2		1	40	40
H1608	001	0	1	04	01	H1608_001_0	5	2	Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H1608	001	0	1	04	01	H1608_001_0	5	3	Fitness-Health Education	10		14c;	2		1	0.00	50.00	2		1	40	40
H1608	001	0	1	04	01	H1608_001_0	5	4	Preventive	01	14a;		2		2			2		1	0	40
H1608	004	0	1	04	01	H1608_004_0	5	1	45% OON	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;12;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;	2		2			2		1	45	45
H1608	004	0	1	04	01	H1608_004_0	5	2	Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H1608	004	0	1	04	01	H1608_004_0	5	3	Fitness-Health Education	10		14c;	2		1	0.00	50.00	2		1	45	45
H1608	004	0	1	04	01	H1608_004_0	5	4	Preventive	01	14a;		2		2			2		1	0	45
H1608	004	0	1	04	01	H1608_004_0	5	5	DME/Diabetic Supplies	01	11a;11b;11c;		2		2			2		1	40	40
H1608	004	0	1	04	01	H1608_004_0	5	6	Dental/Eyewear	10		16a;17b;	2		1	0.00	0.00	2		2		
H1608	007	0	1	04	01	H1608_007_0	5	2	Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H1608	007	0	1	04	01	H1608_007_0	5	1	45% OON	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;12;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;	2		2			2		1	45	45
H1608	007	0	1	04	01	H1608_007_0	5	3	Fitness-Health Education	10		14c;	2		1	0.00	50.00	2		1	45	45
H1608	007	0	1	04	01	H1608_007_0	5	4	Preventive	01	14a;		2		2			2		1	0	45
H1608	007	0	1	04	01	H1608_007_0	5	5	Diabetic Supplies DME	01	11a;11b;11c;		2		2			2		1	40	40
H1608	007	0	1	04	01	H1608_007_0	5	6	Preventive Dental	10		16a;	2		2			1	75.00	1	30	30
H1608	007	0	1	04	01	H1608_007_0	5	7	Eyewear	10		17b;	2		1	0.00	0.00	2		2		
H1608	008	0	1	04	01	H1608_008_0	6	1	45% OON	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;12;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;	2		2			2		1	45	45
H1608	008	0	1	04	01	H1608_008_0	6	2	Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H1608	008	0	1	04	01	H1608_008_0	6	3	Fitness-Health Education	10		14c;	2		1	0.00	50.00	2		1	45	45
H1608	008	0	1	04	01	H1608_008_0	6	4	Preventive	01	14a;		2		2			2		1	0	45
H1608	008	0	1	04	01	H1608_008_0	6	5	Diabetic Supplies DME	01	11a;11b;11c;		2		2			2		1	40	40
H1608	008	0	1	04	01	H1608_008_0	6	6	Preventive Dental	10		16a;	2		2			1	75.00	1	30	30
H1608	008	0	1	04	01	H1608_008_0	6	7	Eyewear	10		17b;	2		1	0.00	0.00	2		2		
H1608	012	0	1	04	01	H1608_012_0	5	2	Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H1608	012	0	1	04	01	H1608_012_0	5	1	40% OON	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;	2		2			2		1	40	40
H1608	012	0	1	04	01	H1608_012_0	5	3	Fitness	10		14c;	2		1	0.00	50.00	2		1	40	40
H1608	012	0	1	04	01	H1608_012_0	5	5	Preventive Dental	10		16a;	2		2			1	75.00	1	30	30
H1608	012	0	1	04	01	H1608_012_0	5	4	Preventive	01	14a;		2		2			2		1	0	40
H1608	013	0	1	04	01	H1608_013_0	6	2	OON Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H1608	013	0	1	04	01	H1608_013_0	6	1	OON Standard Coinsurance	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	7f;9d;14b;16a;17a;17b;18a;	2		2			2		1	30	30
H1608	013	0	1	04	01	H1608_013_0	6	3	OON Supplemental Benefits 14c	10		14c;	2		1	0.00	50.00	2		2		
H1608	013	0	1	04	01	H1608_013_0	6	4	OON Home Health	01	6;		2		2			2		1	0	0
H1608	016	0	1	04	01	H1608_016_0	3	2	OON No cost share	01	6;		2		2			2		1	0	0
H1608	016	0	1	04	01	H1608_016_0	3	1	OON 45% Coinsurance	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;10b;13c;17a;	2		2			2		1	45	45
H1608	016	0	1	04	01	H1608_016_0	3	3	OON 14b & 14c Supplemental Benefits	10		14b;14c;	2		1	50.00	50.00	2		1	45	45
H1608	016	0	1	04	01	H1608_016_0	3	5	20% Coinsurance	01	11a;11b;11c;		2		2			2		1	20	20
H1608	016	0	1	04	01	H1608_016_0	3	4	OON Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H1608	017	0	1	04	01	H1608_017_0	4	1	OON 45% Coinsurance	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;10b;13c;17a;	2		2			2		1	45	45
H1608	017	0	1	04	01	H1608_017_0	4	2	OON No cost share	01	6;		2		2			2		1	0	0
H1608	017	0	1	04	01	H1608_017_0	4	3	OON 14b & 14c Supplemental Benefits	10		14b;14c;	2		1	50.00	50.00	2		1	45	45
H1608	017	0	1	04	01	H1608_017_0	4	4	OON Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H1608	017	0	1	04	01	H1608_017_0	4	5	OON 20% Coinsurance	01	11a;11b;11c;		2		2			2		1	20	20
H1608	018	0	1	04	01	H1608_018_0	3	3	OON 45% Coinsurance	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;17a;	2		2			2		1	45	45
H1608	018	0	1	04	01	H1608_018_0	3	4	OON 14b &14c Supplemental Benefits	10		14b;14c;	2		1	50.00	50.00	2		1	45	45
H1608	018	0	1	04	01	H1608_018_0	3	5	OON 20% Coinsurance	01	11a;11b;11c;		2		2			2		1	20	20
H1608	018	0	1	04	01	H1608_018_0	3	1	OON Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H1608	018	0	1	04	01	H1608_018_0	3	2	OON No Cost Share	11	6;	16a;	2		2			2		1	0	0
H1608	021	0	1	04	01	H1608_021_0	3	4	OON 14b & 14c Supplemental Benefits	10		14b;14c;	2		1	50.00	50.00	2		1	50	50
H1608	021	0	1	04	01	H1608_021_0	3	1	OON Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H1608	021	0	1	04	01	H1608_021_0	3	2	OON No cost share	11	6;	16a;	2		2			2		1	0	0
H1608	021	0	1	04	01	H1608_021_0	3	3	OON 50% Coinsurance	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;17a;	2		2			2		1	50	50
H1608	021	0	1	04	01	H1608_021_0	3	5	Group 5	01	11a;11b;11c;		2		2			2		1	20	20
H1608	023	0	1	04	01	H1608_023_0	3	5	OON 20% Coinsurance	01	11a;11b;11c;		2		2			2		1	20	20
H1608	023	0	1	04	01	H1608_023_0	3	4	OON 14b & 14c Supplemental Benefits	10		14b;14c;	2		1	50.00	50.00	2		1	45	45
H1608	023	0	1	04	01	H1608_023_0	3	3	OON 45% Coinsurance	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;10b;13c;17a;	2		2			2		1	45	45
H1608	023	0	1	04	01	H1608_023_0	3	2	OON No cost share	11	6;	16a;	2		2			2		1	0	0
H1608	023	0	1	04	01	H1608_023_0	3	1	OON Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H1608	024	0	1	04	01	H1608_024_0	4	3	OON 45% Coinsurance	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;17a;	2		2			2		1	45	45
H1608	024	0	1	04	01	H1608_024_0	4	2	OON No cost share	11	6;	16a;	2		2			2		1	0	0
H1608	024	0	1	04	01	H1608_024_0	4	1	OON Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H1608	024	0	1	04	01	H1608_024_0	4	4	OON 14b & 14c Supplemental Benefits	10		14b;14c;	2		1	50.00	50.00	2		1	45	45
H1608	024	0	1	04	01	H1608_024_0	4	5	OON 20% Coinsurance	01	11a;11b;11c;		2		2			2		1	20	20
H1608	025	0	1	04	01	H1608_025_0	6	1	$35 COPAY	01	7a;		2		1	35.00	35.00	2		2		
H1608	025	0	1	04	01	H1608_025_0	6	10	ZERO COPAY	11	14a;14d;14e;17b;	14b;17a;18a;	2		1	0.00	0.00	2		2		
H1608	025	0	1	04	01	H1608_025_0	6	11	COMPREHENSIVE ALLOWANCE $350	10		16b;	2		1	0.00	0.00	2		2		
H1608	025	0	1	04	01	H1608_025_0	6	12	$115.00 ALLOWANCE	10		17b;	2		1	0.00	0.00	2		2		
H1608	025	0	1	04	01	H1608_025_0	6	2	$40 COPAY	01	16b;17a;18a;		2		1	40.00	40.00	2		2		
H1608	025	0	1	04	01	H1608_025_0	6	9	PREVENTIVE ALLOWANCE $150.00	10		16a;	2		1	0.00	0.00	2		2		
H1608	025	0	1	04	01	H1608_025_0	6	4	FITNESS	10		14c;	2		1	0.00	50.00	2		2		
H1608	025	0	1	04	01	H1608_025_0	6	5	30%	01	8b2;11a;11b;		2		2			2		1	30	30
H1608	025	0	1	04	01	H1608_025_0	6	6	$200	01	10a;		2		1	200.00	200.00	2		2		
H1608	025	0	1	04	01	H1608_025_0	6	7	25%	01	8a1;8a2;8b1;8b3;		2		2			2		1	25	25
H1608	025	0	1	04	01	H1608_025_0	6	8	20%	11	3-1;3-2;3-3;5;6;7b;9a;9b;9c;9d;11c;12;15;	9d;	2		2			2		1	20	20
H1608	025	0	1	04	01	H1608_025_0	6	3	$55.00 COPAY	01	7c;7d;7e;7f;7g;7h;7i;		2		1	55.00	55.00	2		2		
H1608	026	0	1	04	01	H1608_026_0	6	1	20% Coinsurance OON	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;14d;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		2			2		1	20	20
H1608	026	0	1	04	01	H1608_026_0	6	9	Preventive Services 0%-20%	01	14a;		2		2			2		1	0	20
H1608	026	0	1	04	01	H1608_026_0	6	8	30% Dental Coinsurance (Non Medicare)	10		16a;	2		2			1	100.00	1	30	30
H1608	026	0	1	04	01	H1608_026_0	6	7	50% Dental Coinsurance (Non Medicare)	10		16b;	2		2			1	100.00	1	50	50
H1608	026	0	1	04	01	H1608_026_0	6	6	Vision OON - $0 Copay	10		17b;	2		1	0.00	0.00	2		2		
H1608	026	0	1	04	01	H1608_026_0	6	5	Supplemental Benefits OON $0-$50	10		14c;	2		1	0.00	50.00	2		2		
H1608	026	0	1	04	01	H1608_026_0	6	4	$0 Copay OON	01	6;		2		1	0.00	0.00	2		2		
H1608	026	0	1	04	01	H1608_026_0	6	3	45% Coinsurance OON	01	5;7e;7h;9c;		2		2			2		1	45	45
H1608	026	0	1	04	01	H1608_026_0	6	2	30% Coinsurance OON	01	10a;11a;11b;11c;12;		2		2			2		1	30	30
H1608	027	0	1	04	01	H1608_027_0	6	6	30% Dental Coinsurance (Non Medicare)	10		16a;	2		2			1	100.00	1	30	30
H1608	027	0	1	04	01	H1608_027_0	6	7	50% Dental Coinsurance (Non Medicare)	10		16b;	2		2			1	100.00	1	50	50
H1608	027	0	1	04	01	H1608_027_0	6	8	$0 Copay OON	01	6;		2		2			2		1	0	0
H1608	027	0	1	04	01	H1608_027_0	6	9	Vision OON - $0 Copay	10		17b;	2		1	0.00	0.00	2		2		
H1608	027	0	1	04	01	H1608_027_0	6	5	Preventive Services 0%-20%	01	14a;		2		2			2		1	0	20
H1608	027	0	1	04	01	H1608_027_0	6	4	Supplemental Benefits OON $0-$50	10		14c;	2		1	0.00	50.00	2		2		
H1608	027	0	1	04	01	H1608_027_0	6	3	45% Coinsurance OON	01	5;7e;7h;9c;		2		2			2		1	45	45
H1608	027	0	1	04	01	H1608_027_0	6	2	30% Coinsurance OON	01	10a;11a;11b;11c;12;		2		2			2		1	30	30
H1608	027	0	1	04	01	H1608_027_0	6	1	20% Coinsurance OON	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;14d;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		2			2		1	20	20
H1608	028	0	1	04	01	H1608_028_0	9	5	$55 Costshare	11	3-2;3-3;7b;7c;7d;7e;7g;7h;7i;14e;16b;17a;18a;	17a;	2		1	55.00	55.00	2		2		
H1608	028	0	1	04	01	H1608_028_0	9	6	$90.00 Allowance	10		17b;	2		2			2		2		
H1608	028	0	1	04	01	H1608_028_0	9	7	$100 Allowance	10		16a;	2		2			2		2		
H1608	028	0	1	04	01	H1608_028_0	9	8	$45 costshare	01	3-1;		2		1	45.00	45.00	2		2		
H1608	028	0	1	04	01	H1608_028_0	9	10	20%	01	12;		2		2			2		1	20	20
H1608	028	0	1	04	01	H1608_028_0	9	1	Coins. 30%	11	5;6;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;15;17b;	9d;	2		2			2		1	30	30
H1608	028	0	1	04	01	H1608_028_0	9	4	$40.00 Costshare	01	7a;		2		1	40.00	40.00	2		2		
H1608	028	0	1	04	01	H1608_028_0	9	3	$50 costshare Fitness facility	10		14c;	2		1	50.00	50.00	2		2		
H1608	028	0	1	04	01	H1608_028_0	9	2	Zero costshare	11	14a;14d;	14b;	2		1	0.00	0.00	2		2		
H1608	028	0	1	04	01	H1608_028_0	9	9	$49 costshare	01	7f;		2		1	49.00	49.00	2		2		
H1608	029	0	1	04	01	H1608_029_0	9	4	Home Health Group	01	6;		2		2			2		1	0	0
H1608	029	0	1	04	01	H1608_029_0	9	3	45% Coinsurance Group	01	5;7e;7h;9c;		2		2			2		1	45	45
H1608	029	0	1	04	01	H1608_029_0	9	2	40% Coinsurance Group	01	11c;		2		2			2		1	40	40
H1608	029	0	1	04	01	H1608_029_0	9	1	30% Coins Medicare Covered Benefit	01	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;11a;11b;12;14d;15;16b;17a;17b;18a;		2		2			2		1	30	30
H1608	029	0	1	04	01	H1608_029_0	9	9	OON with separate office visit cost	01	14e;		2		2			2		1	30	30
H1608	029	0	1	04	01	H1608_029_0	9	8	Non-Medicare 30%	10		7f;9d;17a;18a;	2		2			2		1	30	30
H1608	029	0	1	04	01	H1608_029_0	9	7	Preventive	01	14a;		2		2			2		1	0	30
H1608	029	0	1	04	01	H1608_029_0	9	5	Ambulance	01	10a;		2		1	175.00	175.00	2		2		
H1608	029	0	1	04	01	H1608_029_0	9	6	Fitness	10		14c;	2		1	50.00	50.00	2		2		
H1608	030	0	1	04	01	H1608_030_0	6	1	20% Coinsurance OON	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;14d;15;16b;17a;17b;18a;	7f;9d;17a;18a;	2		2			2		1	20	20
H1608	030	0	1	04	01	H1608_030_0	6	10	Hearing Aid OON	10		18b;	2		2			2		1	50	50
H1608	030	0	1	04	01	H1608_030_0	6	11	$0 Copay OON	10		17b;	2		1	0.00	0.00	2		2		
H1608	030	0	1	04	01	H1608_030_0	6	12	OON services with sep office cost share	01	14e;		2		2			2		1	20	20
H1608	030	0	1	04	01	H1608_030_0	6	2	45% Coinsurance OON	01	5;7e;7h;9c;		2		2			2		1	45	45
H1608	030	0	1	04	01	H1608_030_0	6	9	50% Dental Coinsurance	10		16b;	2		2			1	100.00	1	50	50
H1608	030	0	1	04	01	H1608_030_0	6	4	Ambulance OON	01	10a;		2		1	125.00	125.00	2		2		
H1608	030	0	1	04	01	H1608_030_0	6	5	Gym OON - Monthly Copay	10		14c;	2		1	50.00	50.00	2		2		
H1608	030	0	1	04	01	H1608_030_0	6	6	Cost Sharing 0% - 20%	01	14a;		2		2			2		1	0	20
H1608	030	0	1	04	01	H1608_030_0	6	7	30% Coinsurance OON	01	11a;11b;11c;12;		2		2			2		1	30	30
H1608	030	0	1	04	01	H1608_030_0	6	8	30% Dental Coinsurance (Non Medicare)	10		16a;	2		2			1	100.00	1	30	30
H1608	030	0	1	04	01	H1608_030_0	6	3	0% Coinsurance OON	01	6;		2		2			2		1	0	0
H1608	801	0	1	04	01	H1608_801_0	2	1		01	6;14a;		2		2			2		1	0	0
H1608	801	0	1	04	01	H1608_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1608	802	0	1	04	01	H1608_802_0	2	1		01	6;14a;		2		2			2		1	0	0
H1608	802	0	1	04	01	H1608_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1608	814	0	1	04	01	H1608_814_0	2	1		01	6;14a;		2		2			2		1	0	0
H1608	814	0	1	04	01	H1608_814_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1608	815	0	1	04	01	H1608_815_0	2	1		01	6;14a;		2		2			2		1	0	0
H1608	815	0	1	04	01	H1608_815_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1608	816	0	1	04	01	H1608_816_0	3	1		01	6;14a;		2		2			2		1	0	0
H1608	816	0	1	04	01	H1608_816_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1608	817	0	1	04	01	H1608_817_0	2	1		01	6;14a;		2		2			2		1	0	0
H1608	817	0	1	04	01	H1608_817_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1608	818	0	1	04	01	H1608_818_0	2	1		01	6;14a;		2		2			2		1	0	0
H1608	818	0	1	04	01	H1608_818_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1608	819	0	1	04	01	H1608_819_0	2	1		01	6;14a;		2		2			2		1	0	0
H1608	819	0	1	04	01	H1608_819_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1608	822	0	1	04	01	H1608_822_0	2	1		01	6;14a;		2		2			2		1	0	0
H1608	822	0	1	04	01	H1608_822_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1608	823	0	1	04	01	H1608_823_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1608	823	0	1	04	01	H1608_823_0	2	1		01	6;14a;		2		2			2		1	0	0
H1608	824	0	1	04	01	H1608_824_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1608	824	0	1	04	01	H1608_824_0	2	1		01	6;14a;		2		2			2		1	0	0
H1659	001	0	1	04	01	H1659_001_0	5	15	Outpatient Hosp/ASC/SA/Blood	01	9a;9b;9c;9d;		2		2			2		1	40	40
H1659	001	0	1	04	01	H1659_001_0	5	9	Preventive/Kidney Ed/Diabetes Ed	01	14a;14d;14e;		2		2			2		1	40	40
H1659	001	0	1	04	01	H1659_001_0	5	13	Hearing	01	18a;		2		2			2		1	40	40
H1659	001	0	1	04	01	H1659_001_0	5	12	Eye Exams	11	17a;17b;	14c;17a;17b;	2		2			2		1	40	40
H1659	001	0	1	04	01	H1659_001_0	5	11	Dental Comp (Medicare cov)	01	16b;		2		2			2		1	40	40
H1659	001	0	1	04	01	H1659_001_0	5	10	Part B Rx	01	15;		2		2			2		1	40	40
H1659	001	0	1	04	01	H1659_001_0	5	1	Cardiac/Pulmonary Rehab	01	3-1;3-2;3-3;		2		2			2		1	40	40
H1659	001	0	1	04	01	H1659_001_0	5	2	Chiro, OT, PT, SLP, MH, Psychiatric	01	7b;7c;7d;7e;7f;7g;7h;7i;		2		2			2		1	40	40
H1659	001	0	1	04	01	H1659_001_0	5	3	Partial Hospitalization	01	5;		2		2			2		1	40	40
H1659	001	0	1	04	01	H1659_001_0	5	4	Home Health	01	6;		2		2			2		1	40	40
H1659	001	0	1	04	01	H1659_001_0	5	5	PCP	01	7a;		2		2			2		1	40	40
H1659	001	0	1	04	01	H1659_001_0	5	6	Ambulance	01	10a;		2		2			2		1	40	40
H1659	001	0	1	04	01	H1659_001_0	5	7	DME/Prosthetics/Diabetic	01	11a;11b;11c;		2		2			2		1	40	40
H1659	001	0	1	04	01	H1659_001_0	5	8	ESRD	01	12;		2		2			2		1	40	40
H1659	001	0	1	04	01	H1659_001_0	5	14	Xrays/Diag Proc/Labs/Rad	01	8a1;8a2;8b1;8b2;8b3;		2		2			2		1	40	40
H1659	002	0	1	04	01	H1659_002_0	6	15	Outpatient Hosp/ASC/SA/Blood	01	9a;9b;9c;9d;		2		2			2		1	40	40
H1659	002	0	1	04	01	H1659_002_0	6	14	Xrays/Diag Proc/Labs/Rad	01	8a1;8a2;8b1;8b2;8b3;		2		2			2		1	40	40
H1659	002	0	1	04	01	H1659_002_0	6	13	Hearing	01	18a;		2		2			2		1	40	40
H1659	002	0	1	04	01	H1659_002_0	6	12	Eye Exams	11	17a;17b;	14c;17a;	2		2			2		1	40	40
H1659	002	0	1	04	01	H1659_002_0	6	11	Dental Comp (Medicare cov)	01	16b;		2		2			2		1	40	40
H1659	002	0	1	04	01	H1659_002_0	6	10	Part B Rx	01	15;		2		2			2		1	40	40
H1659	002	0	1	04	01	H1659_002_0	6	1	Cardiac/Pulmonary Rehab	01	3-1;3-2;3-3;		2		2			2		1	40	40
H1659	002	0	1	04	01	H1659_002_0	6	2	Chiro, OT, PT, SLP, MH, Psychiatric	01	7b;7c;7d;7e;7f;7g;7h;7i;		2		2			2		1	40	40
H1659	002	0	1	04	01	H1659_002_0	6	9	Preventive/Kidney Ed/Diabetes Ed	01	14a;14d;14e;		2		2			2		1	40	40
H1659	002	0	1	04	01	H1659_002_0	6	8	ESRD	01	12;		2		2			2		1	40	40
H1659	002	0	1	04	01	H1659_002_0	6	7	DME/Prosthetics/Diabetic	01	11a;11b;11c;		2		2			2		1	40	40
H1659	002	0	1	04	01	H1659_002_0	6	6	Ambulance	01	10a;		2		2			2		1	40	40
H1659	002	0	1	04	01	H1659_002_0	6	5	PCP	01	7a;		2		2			2		1	40	40
H1659	002	0	1	04	01	H1659_002_0	6	4	Home Health	01	6;		2		2			2		1	40	40
H1659	002	0	1	04	01	H1659_002_0	6	3	Partial Hospitalization	01	5;		2		2			2		1	40	40
H1659	003	0	1	04	01	H1659_003_0	5	1	Cardiac/Pulmonary Rehab	01	3-1;3-2;3-3;		2		2			2		1	40	40
H1659	003	0	1	04	01	H1659_003_0	5	9	Preventive/Kidney Ed/Diabetes Ed	01	14a;14d;14e;		2		2			2		1	40	40
H1659	003	0	1	04	01	H1659_003_0	5	11	Dental Comp (Medicare cov)	01	16b;		2		2			2		1	40	40
H1659	003	0	1	04	01	H1659_003_0	5	12	Eye Exams	11	17a;17b;	14c;17a;	2		2			2		1	40	40
H1659	003	0	1	04	01	H1659_003_0	5	13	Hearing	01	18a;		2		2			2		1	40	40
H1659	003	0	1	04	01	H1659_003_0	5	14	Xrays/Diag Proc/Labs/Rad	01	8a1;8a2;8b1;8b2;8b3;		2		2			2		1	40	40
H1659	003	0	1	04	01	H1659_003_0	5	15	Outpatient Hosp/ASC/SA/Blood	01	9a;9b;9c;9d;		2		2			2		1	40	40
H1659	003	0	1	04	01	H1659_003_0	5	8	ESRD	01	12;		2		2			2		1	40	40
H1659	003	0	1	04	01	H1659_003_0	5	7	DME/Prosthetics/Diabetic	01	11a;11b;11c;		2		2			2		1	40	40
H1659	003	0	1	04	01	H1659_003_0	5	6	Ambulance	01	10a;		2		2			2		1	40	40
H1659	003	0	1	04	01	H1659_003_0	5	5	PCP	01	7a;		2		2			2		1	40	40
H1659	003	0	1	04	01	H1659_003_0	5	4	Home Health	01	6;		2		2			2		1	40	40
H1659	003	0	1	04	01	H1659_003_0	5	3	Partial Hospitalization	01	5;		2		2			2		1	40	40
H1659	003	0	1	04	01	H1659_003_0	5	2	Chiro, OT, PT, SLP, MH, Psychiatric	01	7b;7c;7d;7e;7f;7g;7h;7i;		2		2			2		1	40	40
H1659	003	0	1	04	01	H1659_003_0	5	10	Part B Rx	01	15;		2		2			2		1	40	40
H1666	001	0	1	04	01	H1666_001_0	7	7	Eyewear	10		17b;	2		2			2		2		
H1666	001	0	1	04	01	H1666_001_0	7	8	Hearing Aids	10		18b;	2		2			2		2		
H1666	001	0	1	04	01	H1666_001_0	7	9	30% DME	01	11a;		2		2			2		1	30	30
H1666	001	0	1	04	01	H1666_001_0	7	1	40% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;11c;14a;14d;15;16b;17a;17b;18a;	14b;18a;	2		2			2		1	40	40
H1666	001	0	1	04	01	H1666_001_0	7	2	$200 Copay	01	10a;		2		1	200.00	200.00	2		2		
H1666	001	0	1	04	01	H1666_001_0	7	3	20% Coinsurance	01	12;		2		2			2		1	20	20
H1666	001	0	1	04	01	H1666_001_0	7	4	0 Copay/ 0 Coinsurance	11	14e;	14c;	2		2			2		2		
H1666	001	0	1	04	01	H1666_001_0	7	5	$5 Copay	10		16a;	2		1	5.00	5.00	2		2		
H1666	001	0	1	04	01	H1666_001_0	7	6	Eye Exams	10		17a;	2		2			2		2		
H1666	002	0	1	04	01	H1666_002_0	7	1	40% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;11c;14a;14d;15;16b;17a;17b;18a;	14b;18a;	2		2			2		1	40	40
H1666	002	0	1	04	01	H1666_002_0	7	2	$200 Copay	01	10a;		2		1	200.00	200.00	2		2		
H1666	002	0	1	04	01	H1666_002_0	7	3	20% Coinsurance	01	12;		2		2			2		1	20	20
H1666	002	0	1	04	01	H1666_002_0	7	4	0 Copay/ 0 Coinsurance	11	14e;	14c;	2		2			2		2		
H1666	002	0	1	04	01	H1666_002_0	7	9	30% DME	01	11a;		2		2			2		1	30	30
H1666	002	0	1	04	01	H1666_002_0	7	6	Eye Exams	10		17a;	2		2			2		2		
H1666	002	0	1	04	01	H1666_002_0	7	7	Eyewear	10		17b;	2		2			2		2		
H1666	002	0	1	04	01	H1666_002_0	7	8	Hearing Aids	10		18b;	2		2			2		2		
H1666	002	0	1	04	01	H1666_002_0	7	5	$5 Copay	10		16a;	2		1	5.00	5.00	2		2		
H1666	003	0	1	04	01	H1666_003_0	6	3	20% Coinsurance	01	12;		2		2			2		1	20	20
H1666	003	0	1	04	01	H1666_003_0	6	2	$200 Copay	01	10a;		2		1	200.00	200.00	2		2		
H1666	003	0	1	04	01	H1666_003_0	6	1	40% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;11c;14a;14d;15;16b;17a;17b;18a;	14b;18a;	2		2			2		1	40	40
H1666	003	0	1	04	01	H1666_003_0	6	4	0 Copay/ 0 Coinsurance	11	14e;	14c;	2		2			2		2		
H1666	003	0	1	04	01	H1666_003_0	6	9	30% DME	01	11a;		2		2			2		1	30	30
H1666	003	0	1	04	01	H1666_003_0	6	8	Hearing Aids	10		18b;	2		2			2		2		
H1666	003	0	1	04	01	H1666_003_0	6	7	Eyewear	10		17b;	2		2			2		2		
H1666	003	0	1	04	01	H1666_003_0	6	6	Eye Exams	10		17a;	2		2			2		2		
H1666	003	0	1	04	01	H1666_003_0	6	5	$5 Copay	10		16a;	2		1	5.00	5.00	2		2		
H1666	004	0	1	04	01	H1666_004_0	6	1	50% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;11c;14a;14d;15;16b;17a;17b;18a;	14b;18a;	2		2			2		1	50	50
H1666	004	0	1	04	01	H1666_004_0	6	2	$200  Copay	01	10a;		2		1	200.00	200.00	2		2		
H1666	004	0	1	04	01	H1666_004_0	6	7	Hearing Aids	10		18b;	2		2			2		2		
H1666	004	0	1	04	01	H1666_004_0	6	6	Vision Eyewear - Frames	10		17b;	2		2			2		2		
H1666	004	0	1	04	01	H1666_004_0	6	5	Vision Eye Exam	10		17a;	2		2			2		2		
H1666	004	0	1	04	01	H1666_004_0	6	4	0 Copay/ 0 Coinsurance	11	14e;	14c;	2		2			2		2		
H1666	004	0	1	04	01	H1666_004_0	6	3	20% Coinsurance	01	12;		2		2			2		1	20	20
H1666	004	0	1	04	01	H1666_004_0	6	8	40% DME	01	11a;		2		2			2		1	40	40
H1666	005	0	1	04	01	H1666_005_0	6	3	20% Coinsurance	01	12;		2		2			2		1	20	20
H1666	005	0	1	04	01	H1666_005_0	6	2	$200  Copay	01	10a;		2		1	200.00	200.00	2		2		
H1666	005	0	1	04	01	H1666_005_0	6	1	50% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;11c;14a;14d;15;16b;17a;17b;18a;	14b;18a;	2		2			2		1	50	50
H1666	005	0	1	04	01	H1666_005_0	6	4	0 Copay/ 0 Coinsurance	11	14e;	14c;	2		2			2		2		
H1666	005	0	1	04	01	H1666_005_0	6	8	40% DME	01	11a;		2		2			2		1	40	40
H1666	005	0	1	04	01	H1666_005_0	6	7	Hearing Aids	10		18b;	2		2			2		2		
H1666	005	0	1	04	01	H1666_005_0	6	6	Vision Eyewear - Frames	10		17b;	2		2			2		2		
H1666	005	0	1	04	01	H1666_005_0	6	5	Vision Eye Exam	10		17a;	2		2			2		2		
H1666	006	0	1	04	01	H1666_006_0	6	4	0 Copay/ 0 Coinsurance	11	14e;	14c;	2		2			2		2		
H1666	006	0	1	04	01	H1666_006_0	6	3	20% Coinsurance	01	12;		2		2			2		1	20	20
H1666	006	0	1	04	01	H1666_006_0	6	2	$200  Copay	01	10a;		2		1	200.00	200.00	2		2		
H1666	006	0	1	04	01	H1666_006_0	6	1	50% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;11c;14a;14d;15;16b;17a;17b;18a;	14b;18a;	2		2			2		1	50	50
H1666	006	0	1	04	01	H1666_006_0	6	5	Vision Eye Exam	10		17a;	2		2			2		2		
H1666	006	0	1	04	01	H1666_006_0	6	6	Vision Eyewear - Frames	10		17b;	2		2			2		2		
H1666	006	0	1	04	01	H1666_006_0	6	7	Hearing Aids	10		18b;	2		2			2		2		
H1666	006	0	1	04	01	H1666_006_0	6	8	40% DME	01	11a;		2		2			2		1	40	40
H1666	008	0	1	04	01	H1666_008_0	10	4	$0	11	14e;	14c;	2		1	0.00	0.00	2		2		
H1666	008	0	1	04	01	H1666_008_0	10	3	20%	01	12;		2		2			2		1	20	20
H1666	008	0	1	04	01	H1666_008_0	10	2	$200	01	10a;		2		1	200.00	200.00	2		2		
H1666	008	0	1	04	01	H1666_008_0	10	1	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;11c;14a;14d;15;16b;17a;17b;18a;	14b;18a;	2		2			2		1	50	50
H1666	008	0	1	04	01	H1666_008_0	10	5	$40 Allowance	10		17a;	2		2			2		2		
H1666	008	0	1	04	01	H1666_008_0	10	8	40%	01	11a;		2		2			2		1	40	40
H1666	008	0	1	04	01	H1666_008_0	10	7	1000 Allowance	10		18b;	2		2			2		2		
H1666	008	0	1	04	01	H1666_008_0	10	6	$100 Allowance	10		17b;	2		2			2		2		
H1666	009	0	1	04	01	H1666_009_0	11	1	40% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;11c;14a;14d;15;16b;17a;17b;18a;	14b;18a;	2		2			2		1	40	40
H1666	009	0	1	04	01	H1666_009_0	11	2	$200	01	10a;		2		1	200.00	200.00	2		2		
H1666	009	0	1	04	01	H1666_009_0	11	3	20%	01	12;		2		2			2		1	20	20
H1666	009	0	1	04	01	H1666_009_0	11	4	$0 Copay	11	14e;	14c;	2		2			2		2		
H1666	009	0	1	04	01	H1666_009_0	11	9	30%	01	11a;		2		2			2		1	30	30
H1666	009	0	1	04	01	H1666_009_0	11	5	$40.00 Allowance	10		17a;	2		2			2		2		
H1666	009	0	1	04	01	H1666_009_0	11	6	$100.00 Allowance	10		17b;	2		2			2		2		
H1666	009	0	1	04	01	H1666_009_0	11	7	$1000 Allowance	10		18b;	2		2			2		2		
H1666	009	0	1	04	01	H1666_009_0	11	8	$5 Copay Preventive Dental	10		16a;	2		1	5.00	5.00	2		2		
H1666	801	0	1	04	01	H1666_801_0	5	1		01	6;14a;		2		2			2		1	0	0
H1666	801	0	1	04	01	H1666_801_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1666	803	0	1	04	01	H1666_803_0	3	1		01	6;14a;		2		2			2		1	0	0
H1666	803	0	1	04	01	H1666_803_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1666	805	0	1	04	01	H1666_805_0	3	1		01	6;14a;		2		2			2		1	0	0
H1666	805	0	1	04	01	H1666_805_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1716	001	0	1	04	01	H1716_001_0	3	1		11	9d;	9d;17a;	2		1	0.00	0.00	2		2		
H1716	001	0	1	04	01	H1716_001_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H1716	001	0	1	04	01	H1716_001_0	3	3		01	12;		2		2			2		1	0	20
H1716	001	0	1	04	01	H1716_001_0	3	4		01	14a;		2		2			2		1	0	40
H1716	001	0	1	04	01	H1716_001_0	3	9		10		13b;	1	25.00	2			2		1	50	50
H1716	001	0	1	04	01	H1716_001_0	3	6		01	11a;		2		2			2		1	25	25
H1716	001	0	1	04	01	H1716_001_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;17b;18a;	13d;14b;	2		2			2		1	40	40
H1716	001	0	1	04	01	H1716_001_0	3	8		10		13c;14c;	2		2			2		1	50	50
H1716	001	0	1	04	01	H1716_001_0	3	5		01	15;		2		2			2		1	20	40
H1846	001	0	1	04	01	H1846_001_0	8	5	#5 Other Health Care Professionals	01	7g;		2		1	20.00	40.00	2		2		
H1846	001	0	1	04	01	H1846_001_0	8	4	#4 Eye Exam	11	17a;	17a;	2		1	0.00	40.00	2		2		
H1846	001	0	1	04	01	H1846_001_0	8	3	#3 Primary Care Physician / Chiropractic	01	7a;7b;		2		1	20.00	20.00	2		2		
H1846	001	0	1	04	01	H1846_001_0	8	9	#9 Ambulance Services	01	10a;		2		1	250.00	250.00	2		2		
H1846	001	0	1	04	01	H1846_001_0	8	8	#8 Partial Hospitalization	01	5;		2		1	60.00	60.00	2		2		
H1846	001	0	1	04	01	H1846_001_0	8	7	#7 Mental Health / Psy / Substance Abuse	01	7e;7h;9c;		2		1	50.00	50.00	2		2		
H1846	001	0	1	04	01	H1846_001_0	8	2	#2 Preventative/Lab /Education/Traing	11	8a2;14a;14d;14e;	14b;14c;18a;	2		1	0.00	0.00	2		2		
H1846	001	0	1	04	01	H1846_001_0	8	1	#1 Zero Cost Share	11	6;9d;17b;	9d;	2		2			2		2		
H1846	001	0	1	04	01	H1846_001_0	8	10	#10 Diabetes Supplies and Services	01	11c;		2		2			2		1	0	20
H1846	001	0	1	04	01	H1846_001_0	8	11	#11 Medicare Part B  / DME	01	11a;11b;15;		2		2			2		1	20	20
H1846	001	0	1	04	01	H1846_001_0	8	12	#12 OP Services / Rehabilitation	01	3-1;3-2;3-3;7c;7i;8a1;8b1;8b3;9a;9b;		2		2			2		1	20	20
H1846	001	0	1	04	01	H1846_001_0	8	13	#13 End Stage Renal / Therapeutic Rad	01	8b2;12;		2		2			2		1	30	30
H1846	001	0	1	04	01	H1846_001_0	8	14	#14 Hearing Aids	10		18b;	2		1	699.00	999.00	2		2		
H1846	001	0	1	04	01	H1846_001_0	8	6	#6 Specialty Services	01	7d;7f;16b;18a;		2		1	40.00	40.00	2		2		
H1846	003	0	1	04	01	H1846_003_0	10	9	#9 Partial Hospitalization	01	5;		2		1	65.00	65.00	2		2		
H1846	003	0	1	04	01	H1846_003_0	10	6	#6 Routine Eye Exams / Other	11	17a;	17a;	2		1	0.00	50.00	2		2		
H1846	003	0	1	04	01	H1846_003_0	10	7	#7 Other Health Care Professionals	01	7g;		2		1	30.00	50.00	2		2		
H1846	003	0	1	04	01	H1846_003_0	10	8	#8 Specialty Services	01	7d;7e;7f;7h;9c;16b;18a;		2		1	50.00	50.00	2		2		
H1846	003	0	1	04	01	H1846_003_0	10	5	#5 Primary Care Physician	01	7a;		2		1	30.00	30.00	2		2		
H1846	003	0	1	04	01	H1846_003_0	10	4	#4 Chiropractic Services	01	7b;		2		1	20.00	20.00	2		2		
H1846	003	0	1	04	01	H1846_003_0	10	3	#3 Lab	01	8a2;		2		1	15.00	15.00	2		2		
H1846	003	0	1	04	01	H1846_003_0	10	1	#1 Zero Cost Sharing	11	6;9d;17b;	9d;	2		2			2		2		
H1846	003	0	1	04	01	H1846_003_0	10	10	#10 Ambulance Services	01	10a;		2		1	250.00	250.00	2		2		
H1846	003	0	1	04	01	H1846_003_0	10	11	#11 OP Services / Rehabilitation	01	3-1;3-2;3-3;7c;7i;8a1;8b1;8b3;9a;9b;15;		2		2			2		1	20	20
H1846	003	0	1	04	01	H1846_003_0	10	12	#12 Diabetes Supplies / DME	01	11b;11c;		2		2			2		1	0	20
H1846	003	0	1	04	01	H1846_003_0	10	13	#13 End Stage Renal / Therapeutic Rad	01	8b2;12;		2		2			2		1	30	30
H1846	003	0	1	04	01	H1846_003_0	10	14	#14 Hearing Aids	10		18b;	2		1	699.00	999.00	2		2		
H1846	003	0	1	04	01	H1846_003_0	10	15	#15 DME	01	11a;		2		2			2		1	20	20
H1846	003	0	1	04	01	H1846_003_0	10	2	#2 Preventative Ser/Eduction/Training	11	14a;14d;14e;	14b;14c;18a;	2		1	0.00	0.00	2		2		
H1846	801	0	1	04	01	H1846_801_0	2	1		01	6;14a;		2		2			2		1	0	0
H1846	801	0	1	04	01	H1846_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H1846	802	0	1	04	01	H1846_802_0	2	1		01	6;14a;		2		2			2		1	0	0
H1846	802	0	1	04	01	H1846_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2001	001	0	1	04	01	H2001_001_0	2	5	Group 5	10		18b;	2		1	390.00	450.00	2		2		
H2001	001	0	1	04	01	H2001_001_0	2	6	Group 6	01	5;		2		1	75.00	75.00	2		2		
H2001	001	0	1	04	01	H2001_001_0	2	7	Group 7	01	10a;		2		1	250.00	250.00	2		2		
H2001	001	0	1	04	01	H2001_001_0	2	8	Group 8	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
H2001	001	0	1	04	01	H2001_001_0	2	9	Group 9	01	12;		2		2			2		1	20	20
H2001	001	0	1	04	01	H2001_001_0	2	1	Group 1	01	7a;		2		1	35.00	35.00	2		2		
H2001	001	0	1	04	01	H2001_001_0	2	10	Group 10	11	9d;	9d;14c;	2		1	0.00	0.00	2		2		
H2001	001	0	1	04	01	H2001_001_0	2	11	Group 11	01	14a;		2		2			2		1	0	40
H2001	001	0	1	04	01	H2001_001_0	2	12	Group 12	01	6;11a;		2		2			2		1	50	50
H2001	001	0	1	04	01	H2001_001_0	2	13	Group 13	01	7g;		2		1	35.00	50.00	2		2		
H2001	001	0	1	04	01	H2001_001_0	2	14	Group 14	01	8b3;		2		1	21.00	21.00	2		2		
H2001	001	0	1	04	01	H2001_001_0	2	2	Group 2	11	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;18a;	7f;17a;18a;	2		1	50.00	50.00	2		2		
H2001	001	0	1	04	01	H2001_001_0	2	3	Group 3	11	8a1;8b1;8b2;9a;9b;11b;11c;14d;14e;15;17b;	14b;	2		2			2		1	40	40
H2001	001	0	1	04	01	H2001_001_0	2	4	Group 4	01	8a2;		2		1	18.00	18.00	2		2		
H2001	010	0	1	04	01	H2001_010_0	2	1	Group 1	01	7a;		2		1	30.00	30.00	2		2		
H2001	010	0	1	04	01	H2001_010_0	2	10	Group 10	11	9d;	9d;14c;	2		1	0.00	0.00	2		2		
H2001	010	0	1	04	01	H2001_010_0	2	9	Group 9	01	12;		2		2			2		1	20	20
H2001	010	0	1	04	01	H2001_010_0	2	8	Group 8	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
H2001	010	0	1	04	01	H2001_010_0	2	7	Group 7	01	10a;		2		1	250.00	250.00	2		2		
H2001	010	0	1	04	01	H2001_010_0	2	6	Group 6	01	5;		2		1	75.00	75.00	2		2		
H2001	010	0	1	04	01	H2001_010_0	2	5	Group 5	10		18b;	2		1	390.00	450.00	2		2		
H2001	010	0	1	04	01	H2001_010_0	2	4	Group 4	01	8a2;		2		1	20.00	20.00	2		2		
H2001	010	0	1	04	01	H2001_010_0	2	3	Group 3	11	8a1;8b1;8b2;9a;9b;11b;11c;14d;14e;15;17b;	14b;	2		2			2		1	40	40
H2001	010	0	1	04	01	H2001_010_0	2	2	Group 2	11	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;18a;	7f;17a;18a;	2		1	45.00	45.00	2		2		
H2001	010	0	1	04	01	H2001_010_0	2	15	Group 15	10		16a;	2		2			2		1	75	75
H2001	010	0	1	04	01	H2001_010_0	2	11	Group 11	01	14a;		2		2			2		1	0	40
H2001	010	0	1	04	01	H2001_010_0	2	12	Group 12	01	6;11a;		2		2			2		1	50	50
H2001	010	0	1	04	01	H2001_010_0	2	13	Group 13	01	7g;		2		1	30.00	45.00	2		2		
H2001	010	0	1	04	01	H2001_010_0	2	14	Group 14	01	8b3;		2		1	21.00	21.00	2		2		
H2001	816	0	1	04	01	H2001_816_0	1	1		01	6;14a;		2		2			2		1	0	0
H2001	816	0	1	04	01	H2001_816_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2001	817	0	1	04	01	H2001_817_0	1	1		01	6;14a;		2		2			2		1	0	0
H2001	817	0	1	04	01	H2001_817_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2001	818	0	1	04	01	H2001_818_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2001	818	0	1	04	01	H2001_818_0	1	1		01	6;14a;		2		2			2		1	0	0
H2001	819	0	2	04	01	H2001_819_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2001	819	0	2	04	01	H2001_819_0	1	1		01	6;14a;		2		2			2		1	0	0
H2001	820	0	2	04	01	H2001_820_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2001	820	0	2	04	01	H2001_820_0	1	1		01	6;14a;		2		2			2		1	0	0
H2001	821	0	2	04	01	H2001_821_0	1	1		01	6;14a;		2		2			2		1	0	0
H2001	821	0	2	04	01	H2001_821_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2001	822	0	1	04	01	H2001_822_0	1	1		01	6;14a;		2		2			2		1	0	0
H2001	822	0	1	04	01	H2001_822_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2001	823	0	1	04	01	H2001_823_0	1	1		01	6;14a;		2		2			2		1	0	0
H2001	823	0	1	04	01	H2001_823_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2001	824	0	1	04	01	H2001_824_0	1	1		01	6;14a;		2		2			2		1	0	0
H2001	824	0	1	04	01	H2001_824_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2001	825	0	1	04	01	H2001_825_0	1	1		01	6;14a;		2		2			2		1	0	0
H2001	825	0	1	04	01	H2001_825_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2001	826	0	1	04	01	H2001_826_0	1	1		01	6;14a;		2		2			2		1	0	0
H2001	826	0	1	04	01	H2001_826_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2001	827	0	1	04	01	H2001_827_0	1	1		01	6;14a;		2		2			2		1	0	0
H2001	827	0	1	04	01	H2001_827_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2001	828	0	1	04	01	H2001_828_0	1	1		01	6;14a;		2		2			2		1	0	0
H2001	828	0	1	04	01	H2001_828_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2001	829	0	1	04	01	H2001_829_0	1	1		01	6;14a;		2		2			2		1	0	0
H2001	829	0	1	04	01	H2001_829_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2001	830	0	1	04	01	H2001_830_0	1	1		01	6;14a;		2		2			2		1	0	0
H2001	830	0	1	04	01	H2001_830_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2001	831	0	1	04	01	H2001_831_0	1	1		01	6;14a;		2		2			2		1	0	0
H2001	831	0	1	04	01	H2001_831_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2001	832	0	2	04	01	H2001_832_0	1	1		01	6;14a;		2		2			2		1	0	0
H2001	832	0	2	04	01	H2001_832_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2001	833	0	2	04	01	H2001_833_0	1	1		01	6;14a;		2		2			2		1	0	0
H2001	833	0	2	04	01	H2001_833_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2001	834	0	2	04	01	H2001_834_0	1	1		01	6;14a;		2		2			2		1	0	0
H2001	834	0	2	04	01	H2001_834_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2029	001	0	1	04	01	H2029_001_0	4	1		11	9d;17b;	9d;10b;17a;17b;	2		1	0.00	0.00	2		2		
H2029	001	0	1	04	01	H2029_001_0	4	2		01	10a;		2		1	100.00	100.00	2		2		
H2029	001	0	1	04	01	H2029_001_0	4	3		01	12;		2		2			2		1	0	20
H2029	001	0	1	04	01	H2029_001_0	4	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;15;16b;17a;18a;	13c;13d;14b;14c;16a;16b;	2		2			2		1	50	50
H2029	001	0	1	04	01	H2029_001_0	4	5		10		13b;	1	10.00	2			2		1	50	50
H2029	001	0	1	04	01	H2029_001_0	4	6		01	14a;		2		1	0.00	0.00	2		1	50	50
H2029	801	0	1	04	01	H2029_801_0	1	1		01	6;14a;		2		2			2		1	0	0
H2029	801	0	1	04	01	H2029_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2029	802	0	1	04	01	H2029_802_0	1	1		01	6;14a;		2		2			2		1	0	0
H2029	802	0	1	04	01	H2029_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2029	803	0	1	04	01	H2029_803_0	2	1		01	6;14a;		2		2			2		1	0	0
H2029	803	0	1	04	01	H2029_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2029	805	0	2	04	01	H2029_805_0	2	1		01	6;14a;		2		2			2		1	0	0
H2029	805	0	2	04	01	H2029_805_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2029	806	0	2	04	01	H2029_806_0	2	1		01	6;14a;		2		2			2		1	0	0
H2029	806	0	2	04	01	H2029_806_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2029	807	0	2	04	01	H2029_807_0	2	1		01	6;14a;		2		2			2		1	0	0
H2029	807	0	2	04	01	H2029_807_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2228	001	0	1	04	01	H2228_001_0	3	2	Group 2	11	8a2;17b;	17b;	2		1	0.00	0.00	2		2		
H2228	001	0	1	04	01	H2228_001_0	3	5	Group 5	01	14a;		2		2			2		1	0	30
H2228	001	0	1	04	01	H2228_001_0	3	4	Group 4	10		10b;	2		2			2		1	75	75
H2228	001	0	1	04	01	H2228_001_0	3	3	Group 3	01	10a;12;		2		2			2		1	20	20
H2228	001	0	1	04	01	H2228_001_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;	2		2			2		1	30	30
H2228	002	0	1	04	01	H2228_002_0	3	6	Group 6	10		13b;	1	55.00	1	0.00	0.00	2		2		
H2228	002	0	1	04	01	H2228_002_0	3	5	Group 5	01	14a;		2		2			2		1	0	30
H2228	002	0	1	04	01	H2228_002_0	3	4	Group 4	10		10b;	2		2			2		1	75	75
H2228	002	0	1	04	01	H2228_002_0	3	3	Group 3	01	10a;12;		2		2			2		1	20	20
H2228	002	0	1	04	01	H2228_002_0	3	2	Group 2	11	8a2;17b;	17b;	2		1	0.00	0.00	2		2		
H2228	002	0	1	04	01	H2228_002_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;	2		2			2		1	30	30
H2228	010	0	1	04	01	H2228_010_0	4	4	Group 4	10		10b;	2		2			2		1	75	75
H2228	010	0	1	04	01	H2228_010_0	4	3	Group 3	01	10a;12;		2		2			2		1	20	20
H2228	010	0	1	04	01	H2228_010_0	4	6	Group 6	10		13b;	1	80.00	1	0.00	0.00	2		2		
H2228	010	0	1	04	01	H2228_010_0	4	5	Group 5	01	14a;		2		2			2		1	0	30
H2228	010	0	1	04	01	H2228_010_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		1	0.00	0.00	2		2		
H2228	010	0	1	04	01	H2228_010_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		2			2		1	30	30
H2228	011	0	1	04	01	H2228_011_0	3	4	Group 4	01	14a;		2		2			2		1	0	30
H2228	011	0	1	04	01	H2228_011_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		2			2		1	30	30
H2228	011	0	1	04	01	H2228_011_0	3	6	Group 6	01	10a;		2		1	100.00	100.00	2		2		
H2228	011	0	1	04	01	H2228_011_0	3	5	Group 5	01	12;		2		2			2		1	20	20
H2228	011	0	1	04	01	H2228_011_0	3	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		1	0.00	0.00	2		2		
H2228	011	0	1	04	01	H2228_011_0	3	3	Group 3	10		10b;	2		2			2		1	75	75
H2228	012	0	1	04	01	H2228_012_0	2	4	Group 4	01	14a;		2		2			2		1	0	30
H2228	012	0	1	04	01	H2228_012_0	2	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;	2		2			2		1	30	30
H2228	012	0	1	04	01	H2228_012_0	2	6	Group 6	01	10a;		2		1	100.00	100.00	2		2		
H2228	012	0	1	04	01	H2228_012_0	2	5	Group 5	01	12;		2		2			2		1	20	20
H2228	012	0	1	04	01	H2228_012_0	2	2	Group 2	11	8a2;17b;	16a;16b;17b;	2		1	0.00	0.00	2		2		
H2228	012	0	1	04	01	H2228_012_0	2	3	Group 3	10		10b;	2		2			2		1	75	75
H2228	013	0	1	04	01	H2228_013_0	4	4	Group 4	10		10b;	2		2			2		1	75	75
H2228	013	0	1	04	01	H2228_013_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		2			2		1	30	30
H2228	013	0	1	04	01	H2228_013_0	4	6	Group 6	10		13b;	1	85.00	1	0.00	0.00	2		2		
H2228	013	0	1	04	01	H2228_013_0	4	5	Group 5	01	14a;		2		2			2		1	0	30
H2228	013	0	1	04	01	H2228_013_0	4	2	Group 2	11	8a2;17b;	17b;18b;	2		1	0.00	0.00	2		2		
H2228	013	0	1	04	01	H2228_013_0	4	3	Group 3	01	10a;12;		2		2			2		1	20	20
H2228	015	0	1	04	01	H2228_015_0	4	4	Group 4	10		10b;	2		2			2		1	75	75
H2228	015	0	1	04	01	H2228_015_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		2			2		1	30	30
H2228	015	0	1	04	01	H2228_015_0	4	5	Group 5	01	14a;		2		2			2		1	0	30
H2228	015	0	1	04	01	H2228_015_0	4	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		1	0.00	0.00	2		2		
H2228	015	0	1	04	01	H2228_015_0	4	3	Group 3	01	10a;12;		2		2			2		1	20	20
H2228	016	0	1	04	01	H2228_016_0	3	4	Group 4	10		10b;	2		2			2		1	75	75
H2228	016	0	1	04	01	H2228_016_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		2			2		1	30	30
H2228	016	0	1	04	01	H2228_016_0	3	5	Group 5	01	14a;		2		2			2		1	0	30
H2228	016	0	1	04	01	H2228_016_0	3	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		1	0.00	0.00	2		2		
H2228	016	0	1	04	01	H2228_016_0	3	3	Group 3	01	10a;12;		2		2			2		1	20	20
H2228	017	0	1	04	01	H2228_017_0	3	4	Group 4	01	14a;		2		2			2		1	0	30
H2228	017	0	1	04	01	H2228_017_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		2			2		1	30	30
H2228	017	0	1	04	01	H2228_017_0	3	6	Group 6	01	10a;		2		1	100.00	100.00	2		2		
H2228	017	0	1	04	01	H2228_017_0	3	5	Group 5	01	12;		2		2			2		1	20	20
H2228	017	0	1	04	01	H2228_017_0	3	2	Group 2	11	8a2;17b;	16a;16b;17b;18b;	2		1	0.00	0.00	2		2		
H2228	017	0	1	04	01	H2228_017_0	3	3	Group 3	10		10b;	2		2			2		1	75	75
H2228	018	0	1	04	01	H2228_018_0	2	12	Group 12	01	6;11a;		2		2			2		1	50	50
H2228	018	0	1	04	01	H2228_018_0	2	13	Group 13	01	7g;		2		1	30.00	50.00	2		2		
H2228	018	0	1	04	01	H2228_018_0	2	14	Group 14	01	8b3;		2		1	21.00	21.00	2		2		
H2228	018	0	1	04	01	H2228_018_0	2	2	Group 2	11	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;18a;	7f;17a;18a;	2		1	50.00	50.00	2		2		
H2228	018	0	1	04	01	H2228_018_0	2	3	Group 3	11	8a1;8b1;8b2;9a;9b;11b;11c;14d;14e;15;17b;	14b;	2		2			2		1	40	40
H2228	018	0	1	04	01	H2228_018_0	2	4	Group 4	01	8a2;		2		1	20.00	20.00	2		2		
H2228	018	0	1	04	01	H2228_018_0	2	1	Group 1	01	7a;		2		1	30.00	30.00	2		2		
H2228	018	0	1	04	01	H2228_018_0	2	6	Group 6	01	5;		2		1	75.00	75.00	2		2		
H2228	018	0	1	04	01	H2228_018_0	2	7	Group 7	01	10a;		2		1	250.00	250.00	2		2		
H2228	018	0	1	04	01	H2228_018_0	2	8	Group 8	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
H2228	018	0	1	04	01	H2228_018_0	2	9	Group 9	01	12;		2		2			2		1	20	20
H2228	018	0	1	04	01	H2228_018_0	2	11	Group 11	01	14a;		2		2			2		1	0	40
H2228	018	0	1	04	01	H2228_018_0	2	10	Group 10	11	9d;	9d;14c;	2		1	0.00	0.00	2		2		
H2228	018	0	1	04	01	H2228_018_0	2	5	Group 5	10		18b;	2		1	390.00	450.00	2		2		
H2228	019	0	1	04	01	H2228_019_0	5	1	Group 1	01	7a;		2		1	25.00	25.00	2		2		
H2228	019	0	1	04	01	H2228_019_0	5	10	Group 10	11	9d;	9d;14c;	2		1	0.00	0.00	2		2		
H2228	019	0	1	04	01	H2228_019_0	5	11	Group 11	01	14a;		2		2			2		1	0	40
H2228	019	0	1	04	01	H2228_019_0	5	12	Group 12	01	6;11a;		2		2			2		1	50	50
H2228	019	0	1	04	01	H2228_019_0	5	13	Group 13	01	7g;		2		1	25.00	55.00	2		2		
H2228	019	0	1	04	01	H2228_019_0	5	14	Group 14	10		18b;	2		1	390.00	450.00	2		2		
H2228	019	0	1	04	01	H2228_019_0	5	15	Group 15	10		13b;	1	50.00	1	0.00	0.00	2		2		
H2228	019	0	1	04	01	H2228_019_0	5	2	Group 2	11	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;18a;	7f;17a;18a;	2		1	55.00	55.00	2		2		
H2228	019	0	1	04	01	H2228_019_0	5	8	Group 8	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
H2228	019	0	1	04	01	H2228_019_0	5	9	Group 9	01	12;		2		2			2		1	20	20
H2228	019	0	1	04	01	H2228_019_0	5	3	Group 3	11	9a;9b;11b;11c;14d;14e;15;17b;	14b;	2		2			2		1	40	40
H2228	019	0	1	04	01	H2228_019_0	5	4	Group 4	01	8a1;8a2;8b1;8b2;8b3;		2		1	19.00	21.00	2		1	40	40
H2228	019	0	1	04	01	H2228_019_0	5	5	Group 5	10		16a;	2		2			2		1	75	75
H2228	019	0	1	04	01	H2228_019_0	5	6	Group 6	01	5;		2		1	75.00	75.00	2		2		
H2228	019	0	1	04	01	H2228_019_0	5	7	Group 7	01	10a;		2		1	250.00	250.00	2		2		
H2228	020	0	1	04	01	H2228_020_0	2	8	Group 8	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
H2228	020	0	1	04	01	H2228_020_0	2	9	Group 9	01	12;		2		2			2		1	20	20
H2228	020	0	1	04	01	H2228_020_0	2	6	Group 6	01	5;		2		1	75.00	75.00	2		2		
H2228	020	0	1	04	01	H2228_020_0	2	5	Group 5	10		18b;	2		1	390.00	450.00	2		2		
H2228	020	0	1	04	01	H2228_020_0	2	4	Group 4	01	8a2;		2		1	20.00	20.00	2		2		
H2228	020	0	1	04	01	H2228_020_0	2	3	Group 3	11	8a1;8b1;8b2;9a;9b;11b;11c;14d;14e;15;17b;	14b;	2		2			2		1	40	40
H2228	020	0	1	04	01	H2228_020_0	2	2	Group 2	11	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;18a;	7f;17a;18a;	2		1	60.00	60.00	2		2		
H2228	020	0	1	04	01	H2228_020_0	2	15	Group 15	10		13b;	1	50.00	1	0.00	0.00	2		2		
H2228	020	0	1	04	01	H2228_020_0	2	14	Group 14	01	8b3;		2		1	21.00	21.00	2		2		
H2228	020	0	1	04	01	H2228_020_0	2	13	Group 13	01	7g;		2		1	30.00	60.00	2		2		
H2228	020	0	1	04	01	H2228_020_0	2	12	Group 12	01	6;11a;		2		2			2		1	50	50
H2228	020	0	1	04	01	H2228_020_0	2	11	Group 11	01	14a;		2		2			2		1	0	40
H2228	020	0	1	04	01	H2228_020_0	2	10	Group 10	11	9d;	9d;14c;	2		1	0.00	0.00	2		2		
H2228	020	0	1	04	01	H2228_020_0	2	1	Group 1	01	7a;		2		1	30.00	30.00	2		2		
H2228	020	0	1	04	01	H2228_020_0	2	7	Group 7	01	10a;		2		1	250.00	250.00	2		2		
H2228	021	0	1	04	01	H2228_021_0	4	8	Group 8	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
H2228	021	0	1	04	01	H2228_021_0	4	7	Group 7	01	10a;		2		1	250.00	250.00	2		2		
H2228	021	0	1	04	01	H2228_021_0	4	6	Group 6	01	5;		2		1	75.00	75.00	2		2		
H2228	021	0	1	04	01	H2228_021_0	4	5	Group 5	10		18b;	2		1	390.00	450.00	2		2		
H2228	021	0	1	04	01	H2228_021_0	4	4	Group 4	01	8a2;		2		1	20.00	20.00	2		2		
H2228	021	0	1	04	01	H2228_021_0	4	3	Group 3	11	8a1;8b1;8b2;9a;9b;11b;11c;14d;14e;15;17b;	14b;	2		2			2		1	40	40
H2228	021	0	1	04	01	H2228_021_0	4	2	Group 2	11	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;18a;	7f;17a;18a;	2		1	60.00	60.00	2		2		
H2228	021	0	1	04	01	H2228_021_0	4	15	Group 15	10		13b;	1	50.00	1	0.00	0.00	2		2		
H2228	021	0	1	04	01	H2228_021_0	4	14	Group 14	01	8b3;		2		1	21.00	21.00	2		2		
H2228	021	0	1	04	01	H2228_021_0	4	13	Group 13	01	7g;		2		1	25.00	60.00	2		2		
H2228	021	0	1	04	01	H2228_021_0	4	12	Group 12	01	6;11a;		2		2			2		1	50	50
H2228	021	0	1	04	01	H2228_021_0	4	11	Group 11	01	14a;		2		2			2		1	0	40
H2228	021	0	1	04	01	H2228_021_0	4	10	Group 10	11	9d;	9d;14c;	2		1	0.00	0.00	2		2		
H2228	021	0	1	04	01	H2228_021_0	4	1	Group 1	01	7a;		2		1	25.00	25.00	2		2		
H2228	021	0	1	04	01	H2228_021_0	4	9	Group 9	01	12;		2		2			2		1	20	20
H2228	022	0	1	04	01	H2228_022_0	2	1	Group 1	01	7a;		2		1	35.00	35.00	2		2		
H2228	022	0	1	04	01	H2228_022_0	2	10	Group 10	11	9d;	9d;14c;	2		1	0.00	0.00	2		2		
H2228	022	0	1	04	01	H2228_022_0	2	9	Group 9	01	12;		2		2			2		1	20	20
H2228	022	0	1	04	01	H2228_022_0	2	8	Group 8	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
H2228	022	0	1	04	01	H2228_022_0	2	7	Group 7	01	10a;		2		1	250.00	250.00	2		2		
H2228	022	0	1	04	01	H2228_022_0	2	6	Group 6	01	5;		2		1	75.00	75.00	2		2		
H2228	022	0	1	04	01	H2228_022_0	2	5	Group 5	10		18b;	2		1	390.00	450.00	2		2		
H2228	022	0	1	04	01	H2228_022_0	2	4	Group 4	01	8a2;		2		1	19.00	19.00	2		2		
H2228	022	0	1	04	01	H2228_022_0	2	3	Group 3	11	8a1;8b1;8b2;9a;9b;11b;11c;14d;14e;15;17b;	14b;	2		2			2		1	40	40
H2228	022	0	1	04	01	H2228_022_0	2	2	Group 2	11	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;18a;	7f;17a;18a;	2		1	60.00	60.00	2		2		
H2228	022	0	1	04	01	H2228_022_0	2	15	Group 15	10		13b;	1	50.00	1	0.00	0.00	2		2		
H2228	022	0	1	04	01	H2228_022_0	2	14	Group 14	01	8b3;		2		1	21.00	21.00	2		2		
H2228	022	0	1	04	01	H2228_022_0	2	13	Group 13	01	7g;		2		1	35.00	60.00	2		2		
H2228	022	0	1	04	01	H2228_022_0	2	12	Group 12	01	6;11a;		2		2			2		1	50	50
H2228	022	0	1	04	01	H2228_022_0	2	11	Group 11	01	14a;		2		2			2		1	0	40
H2228	023	0	1	04	01	H2228_023_0	2	1	Group 1	01	7a;		2		1	25.00	25.00	2		2		
H2228	023	0	1	04	01	H2228_023_0	2	9	Group 9	01	12;		2		2			2		1	20	20
H2228	023	0	1	04	01	H2228_023_0	2	7	Group 7	01	10a;		2		1	250.00	250.00	2		2		
H2228	023	0	1	04	01	H2228_023_0	2	6	Group 6	01	5;		2		1	75.00	75.00	2		2		
H2228	023	0	1	04	01	H2228_023_0	2	5	Group 5	10		18b;	2		1	390.00	450.00	2		2		
H2228	023	0	1	04	01	H2228_023_0	2	4	Group 4	01	8a2;		2		1	18.00	18.00	2		2		
H2228	023	0	1	04	01	H2228_023_0	2	3	Group 3	01	11b;11c;15;17b;		2		2			2		1	30	30
H2228	023	0	1	04	01	H2228_023_0	2	2	Group 2	11	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;18a;	7f;17a;18a;	2		1	65.00	65.00	2		2		
H2228	023	0	1	04	01	H2228_023_0	2	15	Group 15	01	8b3;		2		1	21.00	21.00	2		2		
H2228	023	0	1	04	01	H2228_023_0	2	14	Group 14	01	7g;		2		1	25.00	65.00	2		2		
H2228	023	0	1	04	01	H2228_023_0	2	13	Group 13	01	6;11a;		2		2			2		1	50	50
H2228	023	0	1	04	01	H2228_023_0	2	12	Group 12	11	8a1;8b1;8b2;9a;9b;14d;14e;	14b;	2		2			2		1	40	40
H2228	023	0	1	04	01	H2228_023_0	2	11	Group 11	01	14a;		2		2			2		1	0	40
H2228	023	0	1	04	01	H2228_023_0	2	10	Group 10	11	9d;	9d;14c;	2		1	0.00	0.00	2		2		
H2228	023	0	1	04	01	H2228_023_0	2	8	Group 8	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
H2228	024	0	1	04	01	H2228_024_0	2	13	Group 13	01	7g;		2		1	35.00	65.00	2		2		
H2228	024	0	1	04	01	H2228_024_0	2	14	Group 14	10		7b;13a;	2		1	65.00	65.00	2		2		
H2228	024	0	1	04	01	H2228_024_0	2	15	Group 15	01	8b3;		2		1	21.00	21.00	2		2		
H2228	024	0	1	04	01	H2228_024_0	2	2	Group 2	11	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;18a;	7f;17a;18a;	2		1	65.00	65.00	2		2		
H2228	024	0	1	04	01	H2228_024_0	2	3	Group 3	11	8a1;8b1;8b2;9a;9b;11b;11c;14d;14e;15;17b;	14b;	2		2			2		1	40	40
H2228	024	0	1	04	01	H2228_024_0	2	4	Group 4	01	8a2;		2		1	19.00	19.00	2		2		
H2228	024	0	1	04	01	H2228_024_0	2	5	Group 5	10		18b;	2		1	390.00	450.00	2		2		
H2228	024	0	1	04	01	H2228_024_0	2	6	Group 6	01	5;		2		1	75.00	75.00	2		2		
H2228	024	0	1	04	01	H2228_024_0	2	7	Group 7	01	10a;		2		1	250.00	250.00	2		2		
H2228	024	0	1	04	01	H2228_024_0	2	8	Group 8	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
H2228	024	0	1	04	01	H2228_024_0	2	9	Group 9	01	12;		2		2			2		1	20	20
H2228	024	0	1	04	01	H2228_024_0	2	1	Group 1	01	7a;		2		1	35.00	35.00	2		2		
H2228	024	0	1	04	01	H2228_024_0	2	10	Group 10	11	9d;	9d;14c;17b;	2		1	0.00	0.00	2		2		
H2228	024	0	1	04	01	H2228_024_0	2	11	Group 11	01	14a;		2		2			2		1	0	40
H2228	024	0	1	04	01	H2228_024_0	2	12	Group 12	01	6;11a;		2		2			2		1	50	50
H2228	025	0	1	04	01	H2228_025_0	1	1	Group 1	01	7a;		2		1	35.00	35.00	2		2		
H2228	025	0	1	04	01	H2228_025_0	1	10	Group 10	11	9d;	9d;14c;17b;	2		1	0.00	0.00	2		2		
H2228	025	0	1	04	01	H2228_025_0	1	9	Group 9	01	12;		2		2			2		1	20	20
H2228	025	0	1	04	01	H2228_025_0	1	8	Group 8	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
H2228	025	0	1	04	01	H2228_025_0	1	7	Group 7	01	10a;		2		1	250.00	250.00	2		2		
H2228	025	0	1	04	01	H2228_025_0	1	6	Group 6	01	5;		2		1	75.00	75.00	2		2		
H2228	025	0	1	04	01	H2228_025_0	1	5	Group 5	10		18b;	2		1	330.00	380.00	2		2		
H2228	025	0	1	04	01	H2228_025_0	1	4	Group 4	01	8a2;		2		1	13.00	13.00	2		2		
H2228	025	0	1	04	01	H2228_025_0	1	3	Group 3	11	8a1;8b1;8b2;9a;9b;11b;11c;14d;14e;15;17b;	14b;	2		2			2		1	40	40
H2228	025	0	1	04	01	H2228_025_0	1	2	Group 2	11	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;18a;	7f;17a;18a;	2		1	65.00	65.00	2		2		
H2228	025	0	1	04	01	H2228_025_0	1	15	Group 15	01	8b3;		2		1	21.00	21.00	2		2		
H2228	025	0	1	04	01	H2228_025_0	1	14	Group 14	10		7b;13a;	2		1	65.00	65.00	2		2		
H2228	025	0	1	04	01	H2228_025_0	1	13	Group 13	01	7g;		2		1	35.00	65.00	2		2		
H2228	025	0	1	04	01	H2228_025_0	1	12	Group 12	01	6;11a;		2		2			2		1	50	50
H2228	025	0	1	04	01	H2228_025_0	1	11	Group 11	01	14a;		2		2			2		1	0	40
H2228	029	0	1	04	01	H2228_029_0	2	8	Group 8	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
H2228	029	0	1	04	01	H2228_029_0	2	7	Group 7	01	10a;		2		1	250.00	250.00	2		2		
H2228	029	0	1	04	01	H2228_029_0	2	6	Group 6	01	5;		2		1	75.00	75.00	2		2		
H2228	029	0	1	04	01	H2228_029_0	2	5	Group 5	10		18b;	2		1	390.00	450.00	2		2		
H2228	029	0	1	04	01	H2228_029_0	2	4	Group 4	01	8a2;		2		1	18.00	18.00	2		2		
H2228	029	0	1	04	01	H2228_029_0	2	3	Group 3	11	8a1;8b1;8b2;9a;9b;11b;11c;14d;14e;15;17b;	14b;	2		2			2		1	30	30
H2228	029	0	1	04	01	H2228_029_0	2	9	Group 9	01	12;		2		2			2		1	20	20
H2228	029	0	1	04	01	H2228_029_0	2	14	Group 14	01	8b3;		2		1	21.00	21.00	2		2		
H2228	029	0	1	04	01	H2228_029_0	2	13	Group 13	01	7g;		2		1	25.00	50.00	2		2		
H2228	029	0	1	04	01	H2228_029_0	2	12	Group 12	01	6;11a;		2		2			2		1	50	50
H2228	029	0	1	04	01	H2228_029_0	2	11	Group 11	01	14a;		2		2			2		1	0	30
H2228	029	0	1	04	01	H2228_029_0	2	10	Group 10	11	9d;	9d;14c;	2		1	0.00	0.00	2		2		
H2228	029	0	1	04	01	H2228_029_0	2	1	Group 1	01	7a;		2		1	25.00	25.00	2		2		
H2228	029	0	1	04	01	H2228_029_0	2	2	Group 2	11	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;18a;	7f;17a;18a;	2		1	50.00	50.00	2		2		
H2228	030	0	1	04	01	H2228_030_0	2	1	Group 1	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8b1;8b2;9a;9b;11b;11c;14d;14e;15;16b;17a;17b;18a;	7f;14b;17a;17b;18a;	2		2			2		1	30	30
H2228	030	0	1	04	01	H2228_030_0	2	10	Group 10	01	6;11a;		2		2			2		1	50	50
H2228	030	0	1	04	01	H2228_030_0	2	11	Group 11	10		18b;	2		1	390.00	450.00	2		2		
H2228	030	0	1	04	01	H2228_030_0	2	12	Group 12	01	8b3;		2		1	21.00	21.00	2		2		
H2228	030	0	1	04	01	H2228_030_0	2	2	Group 2	01	8a2;		2		1	20.00	20.00	2		2		
H2228	030	0	1	04	01	H2228_030_0	2	9	Group 9	01	14a;		2		2			2		1	0	30
H2228	030	0	1	04	01	H2228_030_0	2	4	Group 4	01	5;		2		1	75.00	75.00	2		2		
H2228	030	0	1	04	01	H2228_030_0	2	5	Group 5	01	10a;		2		1	250.00	250.00	2		2		
H2228	030	0	1	04	01	H2228_030_0	2	6	Group 6	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
H2228	030	0	1	04	01	H2228_030_0	2	7	Group 7	01	12;		2		2			2		1	20	20
H2228	030	0	1	04	01	H2228_030_0	2	8	Group 8	11	9d;	9d;14c;	2		1	0.00	0.00	2		2		
H2228	030	0	1	04	01	H2228_030_0	2	3	Group 3	10		16a;	2		2			2		1	75	75
H2228	031	0	1	04	01	H2228_031_0	2	14	Group 14	10		13b;	1	50.00	1	0.00	0.00	2		2		
H2228	031	0	1	04	01	H2228_031_0	2	15	Group 15	01	8b3;		2		1	21.00	21.00	2		2		
H2228	031	0	1	04	01	H2228_031_0	2	2	Group 2	11	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;18a;	7f;17a;18a;	2		1	65.00	65.00	2		2		
H2228	031	0	1	04	01	H2228_031_0	2	3	Group 3	11	8a1;8b1;8b2;9a;9b;11b;11c;14d;14e;15;17b;	14b;	2		2			2		1	30	30
H2228	031	0	1	04	01	H2228_031_0	2	4	Group 4	01	8a2;		2		1	20.00	20.00	2		2		
H2228	031	0	1	04	01	H2228_031_0	2	5	Group 5	10		18b;	2		1	390.00	450.00	2		2		
H2228	031	0	1	04	01	H2228_031_0	2	6	Group 6	01	5;		2		1	75.00	75.00	2		2		
H2228	031	0	1	04	01	H2228_031_0	2	7	Group 7	01	10a;		2		1	250.00	250.00	2		2		
H2228	031	0	1	04	01	H2228_031_0	2	8	Group 8	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
H2228	031	0	1	04	01	H2228_031_0	2	9	Group 9	01	12;		2		2			2		1	20	20
H2228	031	0	1	04	01	H2228_031_0	2	1	Group 1	01	7a;		2		1	35.00	35.00	2		2		
H2228	031	0	1	04	01	H2228_031_0	2	10	Group 10	11	9d;	9d;14c;	2		1	0.00	0.00	2		2		
H2228	031	0	1	04	01	H2228_031_0	2	11	Group 11	01	14a;		2		2			2		1	0	30
H2228	031	0	1	04	01	H2228_031_0	2	12	Group 12	01	6;11a;		2		2			2		1	50	50
H2228	031	0	1	04	01	H2228_031_0	2	13	Group 13	01	7g;		2		1	35.00	65.00	2		2		
H2228	032	0	1	04	01	H2228_032_0	2	15	Group 15	10		13b;	1	50.00	1	0.00	0.00	2		2		
H2228	032	0	1	04	01	H2228_032_0	2	14	Group 14	10		18b;	2		1	390.00	450.00	2		2		
H2228	032	0	1	04	01	H2228_032_0	2	3	Group 3	11	9a;9b;11b;11c;14d;14e;15;17b;	14b;	2		2			2		1	30	30
H2228	032	0	1	04	01	H2228_032_0	2	4	Group 4	01	8a1;8a2;8b1;8b2;8b3;		2		1	20.00	21.00	2		1	30	30
H2228	032	0	1	04	01	H2228_032_0	2	5	Group 5	10		16a;	2		1	40.00	40.00	2		2		
H2228	032	0	1	04	01	H2228_032_0	2	6	Group 6	01	5;		2		1	75.00	75.00	2		2		
H2228	032	0	1	04	01	H2228_032_0	2	7	Group 7	01	10a;		2		1	250.00	250.00	2		2		
H2228	032	0	1	04	01	H2228_032_0	2	8	Group 8	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
H2228	032	0	1	04	01	H2228_032_0	2	9	Group 9	01	12;		2		2			2		1	20	20
H2228	032	0	1	04	01	H2228_032_0	2	2	Group 2	11	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;18a;	7f;17a;18a;	2		1	60.00	60.00	2		2		
H2228	032	0	1	04	01	H2228_032_0	2	13	Group 13	01	7g;		2		1	25.00	60.00	2		2		
H2228	032	0	1	04	01	H2228_032_0	2	12	Group 12	01	6;11a;		2		2			2		1	50	50
H2228	032	0	1	04	01	H2228_032_0	2	11	Group 11	01	14a;		2		2			2		1	0	30
H2228	032	0	1	04	01	H2228_032_0	2	10	Group 10	11	9d;	9d;14c;	2		1	0.00	0.00	2		2		
H2228	032	0	1	04	01	H2228_032_0	2	1	Group 1	01	7a;		2		1	25.00	25.00	2		2		
H2228	033	0	1	04	01	H2228_033_0	2	15	Group 15	01	8b3;		2		1	21.00	21.00	2		2		
H2228	033	0	1	04	01	H2228_033_0	2	1	Group 1	01	7a;		2		1	45.00	45.00	2		2		
H2228	033	0	1	04	01	H2228_033_0	2	3	Group 3	11	8a1;8b1;8b2;9a;9b;11b;11c;14d;14e;17b;	14b;	2		2			2		1	40	40
H2228	033	0	1	04	01	H2228_033_0	2	4	Group 4	01	8a2;		2		1	19.00	19.00	2		2		
H2228	033	0	1	04	01	H2228_033_0	2	5	Group 5	10		18b;	2		1	390.00	450.00	2		2		
H2228	033	0	1	04	01	H2228_033_0	2	6	Group 6	01	5;		2		1	75.00	75.00	2		2		
H2228	033	0	1	04	01	H2228_033_0	2	7	Group 7	01	10a;		2		1	250.00	250.00	2		2		
H2228	033	0	1	04	01	H2228_033_0	2	8	Group 8	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
H2228	033	0	1	04	01	H2228_033_0	2	9	Group 9	01	12;		2		2			2		1	20	20
H2228	033	0	1	04	01	H2228_033_0	2	2	Group 2	11	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;18a;	7f;17a;18a;	2		1	70.00	70.00	2		2		
H2228	033	0	1	04	01	H2228_033_0	2	10	Group 10	11	9d;	9d;14c;	2		1	0.00	0.00	2		2		
H2228	033	0	1	04	01	H2228_033_0	2	11	Group 11	01	6;11a;15;		2		2			2		1	50	50
H2228	033	0	1	04	01	H2228_033_0	2	12	Group 12	01	14a;		2		2			2		1	0	40
H2228	033	0	1	04	01	H2228_033_0	2	13	Group 13	01	7g;		2		1	45.00	70.00	2		2		
H2228	033	0	1	04	01	H2228_033_0	2	14	Group 14	10		16a;	2		1	40.00	40.00	2		2		
H2228	034	0	1	04	01	H2228_034_0	2	15	Group 15	01	8b3;		2		1	21.00	21.00	2		2		
H2228	034	0	1	04	01	H2228_034_0	2	1	Group 1	01	7a;		2		1	20.00	20.00	2		2		
H2228	034	0	1	04	01	H2228_034_0	2	3	Group 3	11	8a1;8b1;8b2;9a;9b;11b;11c;14d;14e;15;17b;	14b;	2		2			2		1	30	30
H2228	034	0	1	04	01	H2228_034_0	2	4	Group 4	01	8a2;		2		1	18.00	18.00	2		2		
H2228	034	0	1	04	01	H2228_034_0	2	5	Group 5	01	6;		2		2			2		1	45	45
H2228	034	0	1	04	01	H2228_034_0	2	6	Group 6	01	5;		2		1	75.00	75.00	2		2		
H2228	034	0	1	04	01	H2228_034_0	2	7	Group 7	01	10a;		2		1	250.00	250.00	2		2		
H2228	034	0	1	04	01	H2228_034_0	2	8	Group 8	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
H2228	034	0	1	04	01	H2228_034_0	2	9	Group 9	01	12;		2		2			2		1	20	20
H2228	034	0	1	04	01	H2228_034_0	2	14	Group 14	10		18b;	2		1	390.00	450.00	2		2		
H2228	034	0	1	04	01	H2228_034_0	2	13	Group 13	01	7g;		2		1	20.00	50.00	2		2		
H2228	034	0	1	04	01	H2228_034_0	2	12	Group 12	01	11a;		2		2			2		1	50	50
H2228	034	0	1	04	01	H2228_034_0	2	11	Group 11	01	14a;		2		2			2		1	0	30
H2228	034	0	1	04	01	H2228_034_0	2	10	Group 10	11	9d;	9d;14c;	2		1	0.00	0.00	2		2		
H2228	034	0	1	04	01	H2228_034_0	2	2	Group 2	11	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;18a;	7f;17a;18a;	2		1	50.00	50.00	2		2		
H2228	035	0	1	04	01	H2228_035_0	2	1	Group 1	01	7a;		2		1	45.00	45.00	2		2		
H2228	035	0	1	04	01	H2228_035_0	2	10	Group 10	11	9d;	9d;14c;	2		1	0.00	0.00	2		2		
H2228	035	0	1	04	01	H2228_035_0	2	11	Group 11	01	14a;		2		2			2		1	0	40
H2228	035	0	1	04	01	H2228_035_0	2	12	Group 12	01	11a;		2		2			2		1	50	50
H2228	035	0	1	04	01	H2228_035_0	2	13	Group 13	01	7g;		2		1	45.00	70.00	2		2		
H2228	035	0	1	04	01	H2228_035_0	2	14	Group 14	10		18b;	2		1	390.00	450.00	2		2		
H2228	035	0	1	04	01	H2228_035_0	2	15	Group 15	01	8b3;		2		1	21.00	21.00	2		2		
H2228	035	0	1	04	01	H2228_035_0	2	2	Group 2	11	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;18a;	7f;17a;18a;	2		1	70.00	70.00	2		2		
H2228	035	0	1	04	01	H2228_035_0	2	3	Group 3	11	8a1;8b1;8b2;9a;9b;11b;11c;14d;14e;15;17b;	14b;	2		2			2		1	40	40
H2228	035	0	1	04	01	H2228_035_0	2	4	Group 4	01	8a2;		2		1	19.00	19.00	2		2		
H2228	035	0	1	04	01	H2228_035_0	2	5	Group 5	01	6;		2		2			2		1	45	45
H2228	035	0	1	04	01	H2228_035_0	2	6	Group 6	01	5;		2		1	75.00	75.00	2		2		
H2228	035	0	1	04	01	H2228_035_0	2	7	Group 7	01	10a;		2		1	250.00	250.00	2		2		
H2228	035	0	1	04	01	H2228_035_0	2	8	Group 8	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
H2228	035	0	1	04	01	H2228_035_0	2	9	Group 9	01	12;		2		2			2		1	20	20
H2228	036	0	1	04	01	H2228_036_0	2	8	Group 8	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
H2228	036	0	1	04	01	H2228_036_0	2	9	Group 9	01	12;		2		2			2		1	20	20
H2228	036	0	1	04	01	H2228_036_0	2	6	Group 6	01	5;		2		1	75.00	75.00	2		2		
H2228	036	0	1	04	01	H2228_036_0	2	5	Group 5	01	6;		2		2			2		1	45	45
H2228	036	0	1	04	01	H2228_036_0	2	4	Group 4	01	8a1;8a2;8b1;8b2;8b3;		2		1	20.00	21.00	2		1	30	30
H2228	036	0	1	04	01	H2228_036_0	2	3	Group 3	11	9a;9b;11b;11c;14d;14e;15;17b;	14b;	2		2			2		1	30	30
H2228	036	0	1	04	01	H2228_036_0	2	2	Group 2	11	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;18a;	7f;17a;18a;	2		1	55.00	55.00	2		2		
H2228	036	0	1	04	01	H2228_036_0	2	15	Group 15	10		16a;	2		2			2		1	75	75
H2228	036	0	1	04	01	H2228_036_0	2	14	Group 14	10		18b;	2		1	390.00	450.00	2		2		
H2228	036	0	1	04	01	H2228_036_0	2	13	Group 13	01	7g;		2		1	15.00	55.00	2		2		
H2228	036	0	1	04	01	H2228_036_0	2	12	Group 12	01	11a;		2		2			2		1	50	50
H2228	036	0	1	04	01	H2228_036_0	2	11	Group 11	01	14a;		2		2			2		1	0	30
H2228	036	0	1	04	01	H2228_036_0	2	10	Group 10	11	9d;	9d;14c;	2		1	0.00	0.00	2		2		
H2228	036	0	1	04	01	H2228_036_0	2	1	Group 1	01	7a;		2		1	15.00	15.00	2		2		
H2228	036	0	1	04	01	H2228_036_0	2	7	Group 7	01	10a;		2		1	250.00	250.00	2		2		
H2228	037	0	1	04	01	H2228_037_0	2	8	Group 8	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
H2228	037	0	1	04	01	H2228_037_0	2	7	Group 7	01	10a;		2		1	250.00	250.00	2		2		
H2228	037	0	1	04	01	H2228_037_0	2	6	Group 6	01	5;		2		1	75.00	75.00	2		2		
H2228	037	0	1	04	01	H2228_037_0	2	5	Group 5	01	6;		2		2			2		1	45	45
H2228	037	0	1	04	01	H2228_037_0	2	4	Group 4	01	8a2;		2		1	19.00	19.00	2		2		
H2228	037	0	1	04	01	H2228_037_0	2	3	Group 3	11	8a1;8b1;8b2;9a;9b;11b;11c;14d;14e;15;17b;	14b;	2		2			2		1	40	40
H2228	037	0	1	04	01	H2228_037_0	2	2	Group 2	11	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;18a;	7f;17a;18a;	2		1	70.00	70.00	2		2		
H2228	037	0	1	04	01	H2228_037_0	2	15	Group 15	01	8b3;		2		1	21.00	21.00	2		2		
H2228	037	0	1	04	01	H2228_037_0	2	14	Group 14	10		18b;	2		1	390.00	450.00	2		2		
H2228	037	0	1	04	01	H2228_037_0	2	13	Group 13	01	7g;		2		1	45.00	70.00	2		2		
H2228	037	0	1	04	01	H2228_037_0	2	12	Group 12	01	11a;		2		2			2		1	50	50
H2228	037	0	1	04	01	H2228_037_0	2	11	Group 11	01	14a;		2		2			2		1	0	40
H2228	037	0	1	04	01	H2228_037_0	2	10	Group 10	11	9d;	9d;14c;	2		1	0.00	0.00	2		2		
H2228	037	0	1	04	01	H2228_037_0	2	1	Group 1	01	7a;		2		1	45.00	45.00	2		2		
H2228	037	0	1	04	01	H2228_037_0	2	9	Group 9	01	12;		2		2			2		1	20	20
H2228	039	0	1	04	01	H2228_039_0	3	2	Group 2	11	8a2;17b;	17b;18b;	2		1	0.00	0.00	2		2		
H2228	039	0	1	04	01	H2228_039_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;18a;	2		2			2		1	30	30
H2228	039	0	1	04	01	H2228_039_0	3	3	Group 3	10		10b;	2		2			2		1	75	75
H2228	039	0	1	04	01	H2228_039_0	3	4	Group 4	01	14a;		2		2			2		1	0	30
H2228	039	0	1	04	01	H2228_039_0	3	5	Group 5	01	12;		2		2			2		1	20	20
H2228	039	0	1	04	01	H2228_039_0	3	6	Group 6	01	10a;		2		1	100.00	100.00	2		2		
H2228	041	0	1	04	01	H2228_041_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;16b;17a;18a;	7f;9d;17a;18a;	2		2			2		1	30	30
H2228	041	0	1	04	01	H2228_041_0	4	2	Group 2	01	14a;		2		2			2		1	0	30
H2228	041	0	1	04	01	H2228_041_0	4	3	Group 3	10		10b;	2		2			2		1	75	75
H2228	041	0	1	04	01	H2228_041_0	4	4	Group 4	01	10a;12;15;		2		2			2		1	20	20
H2228	041	0	1	04	01	H2228_041_0	4	5	Group 5	11	8a2;17b;	14c;16a;16b;17b;18b;	2		1	0.00	0.00	2		2		
H2228	041	0	1	04	01	H2228_041_0	4	6	Group 6	10		13b;	1	100.00	1	0.00	0.00	2		2		
H2228	042	0	1	04	01	H2228_042_0	4	2	Group 2	01	14a;		2		2			2		1	0	30
H2228	042	0	1	04	01	H2228_042_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;16b;17a;18a;	7f;9d;17a;18a;	2		2			2		1	30	30
H2228	042	0	1	04	01	H2228_042_0	4	3	Group 3	10		10b;	2		2			2		1	75	75
H2228	042	0	1	04	01	H2228_042_0	4	6	Group 6	10		13b;	1	90.00	1	0.00	0.00	2		2		
H2228	042	0	1	04	01	H2228_042_0	4	5	Group 5	11	8a2;17b;	16a;16b;17b;18b;	2		1	0.00	0.00	2		2		
H2228	042	0	1	04	01	H2228_042_0	4	4	Group 4	01	10a;12;15;		2		2			2		1	20	20
H2228	043	0	1	04	01	H2228_043_0	3	5	Group 5	11	8a2;17b;	14c;16a;16b;	2		1	0.00	0.00	2		2		
H2228	043	0	1	04	01	H2228_043_0	3	4	Group 4	01	10a;12;15;		2		2			2		1	20	20
H2228	043	0	1	04	01	H2228_043_0	3	3	Group 3	10		13b;	1	100.00	1	0.00	0.00	2		2		
H2228	043	0	1	04	01	H2228_043_0	3	2	Group 2	01	14a;		2		2			2		1	0	30
H2228	043	0	1	04	01	H2228_043_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;16b;17a;18a;	7f;9d;	2		2			2		1	30	30
H2228	044	0	1	04	01	H2228_044_0	3	3	Group 3	10		10b;	2		2			2		1	75	75
H2228	044	0	1	04	01	H2228_044_0	3	4	Group 4	01	10a;12;15;		2		2			2		1	20	20
H2228	044	0	1	04	01	H2228_044_0	3	5	Group 5	11	8a2;17b;	14c;16a;16b;17b;	2		1	0.00	0.00	2		2		
H2228	044	0	1	04	01	H2228_044_0	3	2	Group 2	01	14a;		2		2			2		1	0	30
H2228	044	0	1	04	01	H2228_044_0	3	6	Group 6	10		13b;	1	65.00	1	0.00	0.00	2		2		
H2228	044	0	1	04	01	H2228_044_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;16b;17a;18a;	7f;9d;17a;	2		2			2		1	30	30
H2228	045	0	1	04	01	H2228_045_0	3	6	Group 6	10		13b;	1	75.00	1	0.00	0.00	2		2		
H2228	045	0	1	04	01	H2228_045_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;16b;17a;18a;	7f;9d;17a;	2		2			2		1	30	30
H2228	045	0	1	04	01	H2228_045_0	3	2	Group 2	01	14a;		2		2			2		1	0	30
H2228	045	0	1	04	01	H2228_045_0	3	3	Group 3	10		10b;	2		2			2		1	75	75
H2228	045	0	1	04	01	H2228_045_0	3	4	Group 4	01	10a;12;15;		2		2			2		1	20	20
H2228	045	0	1	04	01	H2228_045_0	3	5	Group 5	11	8a2;17b;	14c;16a;16b;17b;	2		1	0.00	0.00	2		2		
H2228	046	0	1	04	01	H2228_046_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;16b;17a;18a;	7f;9d;17a;18a;	2		2			2		1	30	30
H2228	046	0	1	04	01	H2228_046_0	4	2	Group 2	01	14a;		2		2			2		1	0	30
H2228	046	0	1	04	01	H2228_046_0	4	3	Group 3	10		10b;	2		2			2		1	75	75
H2228	046	0	1	04	01	H2228_046_0	4	4	Group 4	01	10a;12;15;		2		2			2		1	20	20
H2228	046	0	1	04	01	H2228_046_0	4	6	Group 6	10		13b;	1	90.00	1	0.00	0.00	2		2		
H2228	046	0	1	04	01	H2228_046_0	4	5	Group 5	11	8a2;17b;	16a;16b;17b;18b;	2		1	0.00	0.00	2		2		
H2228	805	0	1	04	01	H2228_805_0	1	1		01	6;14a;		2		2			2		1	0	0
H2228	805	0	1	04	01	H2228_805_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2230	002	0	1	04	01	H2230_002_0	5	1		11	3-1;3-2;3-3;5;6;7c;7e;7h;7i;8a1;8a2;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;	9d;15;	2		2			2		1	20	20
H2230	002	0	1	04	01	H2230_002_0	5	9		01	8b1;		2		2			2		1	40	40
H2230	002	0	1	04	01	H2230_002_0	5	8		10		17b;18b;	2		2			2		2		
H2230	002	0	1	04	01	H2230_002_0	5	7		10		14c;	1	500.00	2			2		2		
H2230	002	0	1	04	01	H2230_002_0	5	10		01	15;		2		2			2		1	10	10
H2230	002	0	1	04	01	H2230_002_0	5	5		01	14a;16b;		2		1	45.00	45.00	2		1	20	20
H2230	002	0	1	04	01	H2230_002_0	5	4		01	17b;		2		1	0.00	0.00	2		2		
H2230	002	0	1	04	01	H2230_002_0	5	3		01	10a;		2		1	100.00	100.00	2		2		
H2230	002	0	1	04	01	H2230_002_0	5	2		11	7a;7b;7d;7f;7g;17a;18a;	16a;17a;18a;	2		1	45.00	45.00	2		2		
H2230	002	0	1	04	01	H2230_002_0	5	6		01	12;		2		2			2		1	0	20
H2230	016	0	1	04	01	H2230_016_0	7	6	Group #6	01	10a;		2		1	100.00	100.00	2		2		
H2230	016	0	1	04	01	H2230_016_0	7	5	Group #5	01	17a;		2		1	0.00	40.00	2		2		
H2230	016	0	1	04	01	H2230_016_0	7	4	Group #4	11	7d;7e;7g;7h;9c;16b;	16a;17a;	2		1	40.00	40.00	2		2		
H2230	016	0	1	04	01	H2230_016_0	7	3	Group #3	11	7f;18a;	18a;	2		1	20.00	40.00	2		2		
H2230	016	0	1	04	01	H2230_016_0	7	2	Group #2	11	6;8b2;9d;11c;12;14a;14d;17b;	9d;15;	2		1	0.00	0.00	2		2		
H2230	016	0	1	04	01	H2230_016_0	7	14	Group #14	10		17b;	2		2			2		2		
H2230	016	0	1	04	01	H2230_016_0	7	13	Group #13	10		14c;	1	500.00	2			2		2		
H2230	016	0	1	04	01	H2230_016_0	7	12	Group #12	01	5;		2		1	55.00	55.00	2		2		
H2230	016	0	1	04	01	H2230_016_0	7	11	Group #11	01	14e;		2		1	0.00	0.00	2		2		
H2230	016	0	1	04	01	H2230_016_0	7	10	Group #10	01	8b1;		2		1	250.00	250.00	2		2		
H2230	016	0	1	04	01	H2230_016_0	7	1	Group #1	01	3-1;3-2;3-3;7a;7b;7c;7i;8a1;8a2;8b3;		2		1	20.00	20.00	2		2		
H2230	016	0	1	04	01	H2230_016_0	7	7	Group #7	01	11a;11b;		2		2			2		1	20	20
H2230	016	0	1	04	01	H2230_016_0	7	9	Group #9	01	9a;9b;		2		1	225.00	225.00	2		2		
H2230	016	0	1	04	01	H2230_016_0	7	8	Group #8	01	15;		2		2			2		1	15	15
H2230	017	0	1	04	01	H2230_017_0	6	1		01	11a;11b;12;15;		2		2			2		1	20	20
H2230	017	0	1	04	01	H2230_017_0	6	10	Group #10	01	8b2;		2		1	60.00	60.00	2		2		
H2230	017	0	1	04	01	H2230_017_0	6	9	Group #9	01	17a;		2		1	0.00	45.00	2		2		
H2230	017	0	1	04	01	H2230_017_0	6	8	Group #8	01	9a;9b;		2		1	300.00	300.00	2		2		
H2230	017	0	1	04	01	H2230_017_0	6	7	Group #7	01	7a;		2		1	25.00	25.00	2		2		
H2230	017	0	1	04	01	H2230_017_0	6	11	Group #11	01	5;		2		1	55.00	55.00	2		2		
H2230	017	0	1	04	01	H2230_017_0	6	12	Group #12	01	8a1;8a2;8b3;		2		1	30.00	30.00	2		2		
H2230	017	0	1	04	01	H2230_017_0	6	13	Group #13	01	7f;7g;18a;		2		1	25.00	45.00	2		2		
H2230	017	0	1	04	01	H2230_017_0	6	14	Group #14	01	7b;		2		1	20.00	20.00	2		2		
H2230	017	0	1	04	01	H2230_017_0	6	15	Group #15	01	8b1;		2		1	325.00	325.00	2		2		
H2230	017	0	1	04	01	H2230_017_0	6	2		11	6;9d;11c;14a;14d;14e;17b;	9d;15;	2		1	0.00	0.00	2		2		
H2230	017	0	1	04	01	H2230_017_0	6	3		11	3-1;3-2;3-3;7d;16b;	16a;	2		1	45.00	45.00	2		2		
H2230	017	0	1	04	01	H2230_017_0	6	4	Group #4	01	7c;7e;7h;7i;9c;		2		1	40.00	40.00	2		2		
H2230	017	0	1	04	01	H2230_017_0	6	5	Group #5	01	10a;		2		1	250.00	250.00	2		2		
H2230	017	0	1	04	01	H2230_017_0	6	6		10		14c;	1	500.00	1	0.00	0.00	2		2		
H2230	801	0	1	04	01	H2230_801_0	4	1		01	6;14a;		2		2			2		1	0	0
H2230	801	0	1	04	01	H2230_801_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2230	809	0	1	04	01	H2230_809_0	4	1		01	6;14a;		2		2			2		1	0	0
H2230	809	0	1	04	01	H2230_809_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2322	004	0	1	04	01	H2322_004_0	7	2	OON Medicare Covered Grp 2	01	5;7e;7h;9c;11a;11b;		2		2			2		1	50	50
H2322	004	0	1	04	01	H2322_004_0	7	3	OON Enhanced Group 3	10		14c;	1	40.00	2			2		2		
H2322	004	0	1	04	01	H2322_004_0	7	1	OON Medicare Covered & Enhanced Group 1	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;10a;11c;12;14a;14d;14e;15;16b;17a;18a;	9d;17a;18a;	2		2			2		1	20	20
H2322	004	0	1	04	01	H2322_004_0	7	4	Enhanced Group 4	11	17b;	17b;	2		2			2		1	50	50
H2322	008	0	1	04	01	H2322_008_0	7	4	Enhanced Group 4	11	17b;	17b;	2		2			2		1	50	50
H2322	008	0	1	04	01	H2322_008_0	7	1	OON Medicare Covered & Enhanced Group 1	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;10a;11c;12;14a;14d;14e;15;16b;17a;18a;	9d;17a;18a;	2		2			2		1	25	25
H2322	008	0	1	04	01	H2322_008_0	7	3	OON Enhanced Group 3	10		14c;	1	25.00	2			2		2		
H2322	008	0	1	04	01	H2322_008_0	7	2	OON Medicare Covered Grp 2	01	5;7e;7h;9c;11a;11b;		2		2			2		1	50	50
H2322	801	0	1	04	01	H2322_801_0	5	1		01	6;14a;		2		2			2		1	0	0
H2322	801	0	1	04	01	H2322_801_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2322	803	0	1	04	01	H2322_803_0	5	1		01	6;14a;		2		2			2		1	0	0
H2322	803	0	1	04	01	H2322_803_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2322	809	0	1	04	01	H2322_809_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2322	809	0	1	04	01	H2322_809_0	5	1		01	6;14a;		2		2			2		1	0	0
H2406	001	0	1	04	01	H2406_001_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;17a;	2		2			2		1	30	30
H2406	001	0	1	04	01	H2406_001_0	3	2	Group 2	11	8a2;17b;	16a;16b;17b;	2		1	0.00	0.00	2		2		
H2406	001	0	1	04	01	H2406_001_0	3	3	Group 3	01	10a;12;		2		2			2		1	20	20
H2406	001	0	1	04	01	H2406_001_0	3	4	Group 4	10		10b;	2		2			2		1	75	75
H2406	001	0	1	04	01	H2406_001_0	3	5	Group 5	01	14a;		2		2			2		1	0	30
H2406	001	0	1	04	01	H2406_001_0	3	6	Group 6	10		13b;	1	110.00	1	0.00	0.00	2		2		
H2406	805	0	1	04	01	H2406_805_0	1	1		01	6;14a;		2		2			2		1	0	0
H2406	805	0	1	04	01	H2406_805_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2411	803	0	1	04	01	H2411_803_0	2	1		01	6;14a;		2		2			2		1	0	0
H2411	803	0	1	04	01	H2411_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2591	001	0	1	04	01	H2591_001_0	5	1	Office Visits	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9c;14a;14d;14e;15;16b;17a;18a;	14b;	2		2			2		1	30	30
H2591	001	0	1	04	01	H2591_001_0	5	2	Renal Dialysis	11	9d;12;	9d;	2		2			2		1	30	30
H2591	001	0	1	04	01	H2591_001_0	5	3	Ambulance	01	10a;		2		1	250.00	250.00	2		2		
H2591	001	0	1	04	01	H2591_001_0	5	4	DME	01	11a;11b;11c;		2		2			2		1	30	30
H2591	001	0	1	04	01	H2591_001_0	5	5	ASC	01	9a;9b;		2		2			2		1	30	30
H2591	001	0	1	04	01	H2591_001_0	5	6	Dental, Vision, and Hearing	11	17b;	16a;16b;17a;17b;18a;18b;	2		2			2		2		
H2591	001	0	1	04	01	H2591_001_0	5	7	Other Services	10		14c;	2		2			2		2		
H2591	801	0	1	04	01	H2591_801_0	2	1		01	6;14a;		2		2			2		1	0	0
H2591	801	0	1	04	01	H2591_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2591	802	0	1	04	01	H2591_802_0	2	1		01	6;14a;		2		2			2		1	0	0
H2591	802	0	1	04	01	H2591_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2591	803	0	1	04	01	H2591_803_0	2	1		01	6;14a;		2		2			2		1	0	0
H2591	803	0	1	04	01	H2591_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2676	001	0	1	04	01	H2676_001_0	5	1	30% Coinsurance	11	3-1;3-2;3-3;5;7e;7h;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;15;16b;	9d;	2		2			2		1	30	30
H2676	001	0	1	04	01	H2676_001_0	5	10	0%-30%	10		17b;	2		2			2		1	0	30
H2676	001	0	1	04	01	H2676_001_0	5	11		10		18b;	2		2			2		1	50	50
H2676	001	0	1	04	01	H2676_001_0	5	2	$40 Copay	01	6;7a;		2		1	40.00	40.00	2		2		
H2676	001	0	1	04	01	H2676_001_0	5	3	$60 Copay	01	7b;7c;7d;7f;7i;		2		1	60.00	60.00	2		2		
H2676	001	0	1	04	01	H2676_001_0	5	9	$0 Copay	10		14c;	2		2			2		2		
H2676	001	0	1	04	01	H2676_001_0	5	5	50% Coinsurance	10		16a;18a;	2		2			2		1	50	50
H2676	001	0	1	04	01	H2676_001_0	5	6	$0-$60 Copay	11	17a;	17a;	2		1	0.00	60.00	2		2		
H2676	001	0	1	04	01	H2676_001_0	5	7	0%-30%	01	17b;		2		2			2		1	0	30
H2676	001	0	1	04	01	H2676_001_0	5	8	Ambulance	01	10a;		2		1	200.00	200.00	2		1	20	20
H2676	001	0	1	04	01	H2676_001_0	5	4	$40-$60 Copay	01	7g;14a;14d;14e;18a;		2		1	40.00	60.00	2		2		
H2701	003	0	1	04	01	H2701_003_0	10	1	Benfits with $50 Copay	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b3;9c;9d;14d;14e;16b;17a;18a;	9d;14b;14c;17a;	2		1	50.00	50.00	2		2		
H2701	003	0	1	04	01	H2701_003_0	10	2	Benefits with 20% Coinsurance	01	11a;11b;11c;12;15;		2		2			2		1	20	20
H2701	003	0	1	04	01	H2701_003_0	10	3	Ambulance	01	10a;		2		1	100.00	100.00	2		2		
H2701	003	0	1	04	01	H2701_003_0	10	4	Benefits with $0	01	6;17b;		2		2			2		2		
H2701	003	0	1	04	01	H2701_003_0	10	5	Hospital Facility/ASC	01	9a;9b;		2		1	500.00	500.00	2		2		
H2701	003	0	1	04	01	H2701_003_0	10	6	Diagnostic Radiology (CT MRI PET)	01	8b1;		2		1	250.00	400.00	2		2		
H2701	003	0	1	04	01	H2701_003_0	10	7	Therapeutic Radiology	01	8b2;		2		2			2		1	30	30
H2701	003	0	1	04	01	H2701_003_0	10	8	Medicare Covered Preventive Services	01	14a;		2		2			2		2		
H2701	006	0	1	04	01	H2701_006_0	10	1	Benefits wtih $50 copay	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b3;9c;9d;14d;14e;16b;17a;18a;	9d;14b;14c;17a;	2		1	50.00	50.00	2		2		
H2701	006	0	1	04	01	H2701_006_0	10	8	Medicare covered Preventive Services	01	14a;		2		2			2		2		
H2701	006	0	1	04	01	H2701_006_0	10	2	Benefits with 20% Coinsurance	01	11a;11b;11c;12;15;		2		2			2		1	20	20
H2701	006	0	1	04	01	H2701_006_0	10	3	Ambulance	01	10a;		2		1	100.00	100.00	2		2		
H2701	006	0	1	04	01	H2701_006_0	10	4	Benefits with $0 Copay	01	6;17b;		2		2			2		2		
H2701	006	0	1	04	01	H2701_006_0	10	5	Hospital Facility/ASC	01	9a;9b;		2		1	500.00	500.00	2		2		
H2701	006	0	1	04	01	H2701_006_0	10	6	Diagnostic Radiology (CT MRI PET)	01	8b1;		2		1	300.00	400.00	2		2		
H2701	006	0	1	04	01	H2701_006_0	10	7	Therapeutic Radioligy 30%	01	8b2;		2		2			2		1	30	30
H2701	806	0	1	04	01	H2701_806_0	5	1		01	6;14a;		2		2			2		1	0	0
H2701	806	0	1	04	01	H2701_806_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2701	807	0	1	04	01	H2701_807_0	5	1		01	6;14a;		2		2			2		1	0	0
H2701	807	0	1	04	01	H2701_807_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2775	082	0	1	04	01	H2775_082_0	6	4		01	7d;16b;		2		1	35.00	35.00	2		2		
H2775	082	0	1	04	01	H2775_082_0	6	5		01	10a;		2		1	300.00	300.00	2		2		
H2775	082	0	1	04	01	H2775_082_0	6	3		01	7a;7g;		2		1	10.00	10.00	2		2		
H2775	082	0	1	04	01	H2775_082_0	6	2		01	7b;		2		2			2		1	20	20
H2775	082	0	1	04	01	H2775_082_0	6	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;17b;18a;	9d;14c;18a;	2		2			2		1	20	20
H2775	082	0	1	04	01	H2775_082_0	6	6		11	8a1;8a2;8b1;8b2;8b3;14e;17a;	17a;	2		2			2		1	20	20
H2775	083	0	1	04	01	H2775_083_0	6	2		01	7b;		2		2			2		1	20	20
H2775	083	0	1	04	01	H2775_083_0	6	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;17b;18a;	9d;14c;18a;	2		2			2		1	20	20
H2775	083	0	1	04	01	H2775_083_0	6	3		01	7a;7g;		2		1	10.00	10.00	2		2		
H2775	083	0	1	04	01	H2775_083_0	6	6		11	8a1;8a2;8b1;8b2;8b3;14e;17a;	17a;	2		2			2		1	20	20
H2775	083	0	1	04	01	H2775_083_0	6	5		01	10a;		2		1	300.00	300.00	2		2		
H2775	083	0	1	04	01	H2775_083_0	6	4		01	7d;16b;		2		1	35.00	35.00	2		2		
H2775	088	0	1	04	01	H2775_088_0	6	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;17b;18a;	9d;14c;18a;	2		2			2		1	20	20
H2775	088	0	1	04	01	H2775_088_0	6	2		01	7b;		2		2			2		1	20	20
H2775	088	0	1	04	01	H2775_088_0	6	5		01	10a;		2		1	300.00	300.00	2		2		
H2775	088	0	1	04	01	H2775_088_0	6	4		01	7d;16b;		2		1	60.00	60.00	2		2		
H2775	088	0	1	04	01	H2775_088_0	6	3		01	7a;7g;		2		1	25.00	25.00	2		2		
H2775	088	0	1	04	01	H2775_088_0	6	6		11	8a1;8a2;8b1;8b2;8b3;14e;17a;	17a;	2		2			2		1	20	20
H2775	089	0	1	04	01	H2775_089_0	6	5		01	10a;		2		1	300.00	300.00	2		2		
H2775	089	0	1	04	01	H2775_089_0	6	4		01	7d;16b;		2		1	60.00	60.00	2		2		
H2775	089	0	1	04	01	H2775_089_0	6	3		01	7a;7g;		2		1	25.00	25.00	2		2		
H2775	089	0	1	04	01	H2775_089_0	6	2		01	7b;		2		2			2		1	20	20
H2775	089	0	1	04	01	H2775_089_0	6	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;17b;18a;	9d;14c;18a;	2		2			2		1	20	20
H2775	089	0	1	04	01	H2775_089_0	6	6		11	8a1;8a2;8b1;8b2;8b3;14e;17a;	17a;	2		2			2		1	20	20
H2775	095	0	1	04	01	H2775_095_0	5	5		01	10a;		2		1	300.00	300.00	2		2		
H2775	095	0	1	04	01	H2775_095_0	5	4		01	7d;16b;		2		1	50.00	50.00	2		2		
H2775	095	0	1	04	01	H2775_095_0	5	3		01	7a;7g;		2		1	10.00	10.00	2		2		
H2775	095	0	1	04	01	H2775_095_0	5	2		01	7b;		2		2			2		1	20	20
H2775	095	0	1	04	01	H2775_095_0	5	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;17b;18a;	9d;14c;18a;	2		2			2		1	20	20
H2775	095	0	1	04	01	H2775_095_0	5	6		11	8a1;8a2;8b1;8b2;8b3;14e;17a;	17a;	2		2			2		1	20	20
H2775	099	0	1	04	01	H2775_099_0	6	5		01	10a;		2		1	300.00	300.00	2		2		
H2775	099	0	1	04	01	H2775_099_0	6	4		01	7d;16b;		2		1	50.00	50.00	2		2		
H2775	099	0	1	04	01	H2775_099_0	6	3		01	7a;7g;		2		1	20.00	20.00	2		2		
H2775	099	0	1	04	01	H2775_099_0	6	2		01	7b;		2		2			2		1	20	20
H2775	099	0	1	04	01	H2775_099_0	6	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;17b;18a;	9d;14c;18a;	2		2			2		1	20	20
H2775	099	0	1	04	01	H2775_099_0	6	6		11	8a1;8a2;8b1;8b2;8b3;14e;17a;	17a;	2		2			2		1	20	20
H2775	100	0	1	04	01	H2775_100_0	6	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;17b;18a;	9d;14c;18a;	2		2			2		1	20	20
H2775	100	0	1	04	01	H2775_100_0	6	2		01	7b;		2		2			2		1	20	20
H2775	100	0	1	04	01	H2775_100_0	6	3		01	7a;7g;		2		1	30.00	30.00	2		2		
H2775	100	0	1	04	01	H2775_100_0	6	4		01	7d;16b;		2		1	60.00	60.00	2		2		
H2775	100	0	1	04	01	H2775_100_0	6	5		01	10a;		2		1	300.00	300.00	2		2		
H2775	100	0	1	04	01	H2775_100_0	6	6		11	8a1;8a2;8b1;8b2;8b3;14e;17a;	17a;	2		2			2		1	20	20
H2775	801	0	1	04	01	H2775_801_0	6	1		01	6;14a;		2		2			2		1	0	0
H2775	801	0	1	04	01	H2775_801_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2775	802	0	1	04	01	H2775_802_0	6	1		01	6;14a;		2		2			2		1	0	0
H2775	802	0	1	04	01	H2775_802_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2775	803	0	1	04	01	H2775_803_0	6	1		01	6;14a;		2		2			2		1	0	0
H2775	803	0	1	04	01	H2775_803_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2816	001	0	1	09	04	H2816_001_0	5	5		01	10a;				1	300.00	300.00	2		2		
H2816	001	0	1	09	04	H2816_001_0	5	4		01	7d;16b;				1	35.00	35.00	2		2		
H2816	001	0	1	09	04	H2816_001_0	5	3		01	7a;7g;				1	10.00	10.00	2		2		
H2816	001	0	1	09	04	H2816_001_0	5	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;17b;18a;	9d;14c;18a;	2		2			2		1	20	20
H2816	001	0	1	09	04	H2816_001_0	5	2		01	7b;				2			2		1	20	20
H2816	001	0	1	09	04	H2816_001_0	5	6		11	8a1;8a2;8b1;8b2;8b3;14e;17a;	17a;	2		2			2		1	20	20
H2816	002	0	1	09	04	H2816_002_0	5	5		01	10a;				1	300.00	300.00	2		2		
H2816	002	0	1	09	04	H2816_002_0	5	4		01	7d;16b;				1	35.00	35.00	2		2		
H2816	002	0	1	09	04	H2816_002_0	5	3		01	7a;7g;				1	10.00	10.00	2		2		
H2816	002	0	1	09	04	H2816_002_0	5	2		01	7b;				2			2		1	20	20
H2816	002	0	1	09	04	H2816_002_0	5	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;17b;18a;	9d;14c;18a;	2		2			2		1	20	20
H2816	002	0	1	09	04	H2816_002_0	5	6		11	8a1;8a2;8b1;8b2;8b3;14e;17a;	17a;	2		2			2		1	20	20
H2816	007	0	1	09	04	H2816_007_0	5	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;17b;18a;	9d;14c;18a;	2		2			2		1	20	20
H2816	007	0	1	09	04	H2816_007_0	5	2		01	7b;				2			2		1	20	20
H2816	007	0	1	09	04	H2816_007_0	5	3		01	7a;7g;				1	10.00	10.00	2		2		
H2816	007	0	1	09	04	H2816_007_0	5	4		01	7d;16b;				1	50.00	50.00	2		2		
H2816	007	0	1	09	04	H2816_007_0	5	5		01	10a;				1	300.00	300.00	2		2		
H2816	007	0	1	09	04	H2816_007_0	5	6		11	8a1;8a2;8b1;8b2;8b3;14e;17a;	17a;	2		2			2		1	20	20
H2816	008	0	1	09	04	H2816_008_0	5	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;17b;18a;	9d;14c;18a;	2		2			2		1	20	20
H2816	008	0	1	09	04	H2816_008_0	5	2		01	7b;				2			2		1	20	20
H2816	008	0	1	09	04	H2816_008_0	5	3		01	7a;7g;				1	10.00	10.00	2		2		
H2816	008	0	1	09	04	H2816_008_0	5	4		01	7d;16b;				1	50.00	50.00	2		2		
H2816	008	0	1	09	04	H2816_008_0	5	5		01	10a;				1	300.00	300.00	2		2		
H2816	008	0	1	09	04	H2816_008_0	5	6		11	8a1;8a2;8b1;8b2;8b3;14e;17a;	17a;	2		2			2		1	20	20
H2816	013	0	1	09	04	H2816_013_0	6	2		01	7b;				2			2		1	20	20
H2816	013	0	1	09	04	H2816_013_0	6	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;17b;18a;	9d;14c;18a;	2		2			2		1	20	20
H2816	013	0	1	09	04	H2816_013_0	6	3		01	7a;7g;				1	10.00	10.00	2		2		
H2816	013	0	1	09	04	H2816_013_0	6	6		11	8a1;8a2;8b1;8b2;8b3;14e;17a;	17a;	2		2			2		1	20	20
H2816	013	0	1	09	04	H2816_013_0	6	5		01	10a;				1	300.00	300.00	2		2		
H2816	013	0	1	09	04	H2816_013_0	6	4		01	7d;16b;				1	35.00	35.00	2		2		
H2816	019	0	1	09	04	H2816_019_0	6	5		01	10a;				1	300.00	300.00	2		2		
H2816	019	0	1	09	04	H2816_019_0	6	4		01	7d;16b;				1	60.00	60.00	2		2		
H2816	019	0	1	09	04	H2816_019_0	6	3		01	7a;7g;				1	25.00	25.00	2		2		
H2816	019	0	1	09	04	H2816_019_0	6	2		01	7b;				2			2		1	20	20
H2816	019	0	1	09	04	H2816_019_0	6	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;17b;18a;	9d;14c;18a;	2		2			2		1	20	20
H2816	019	0	1	09	04	H2816_019_0	6	6		11	8a1;8a2;8b1;8b2;8b3;14e;17a;	17a;	2		2			2		1	20	20
H2816	021	0	1	09	04	H2816_021_0	6	5		01	10a;				1	300.00	300.00	2		2		
H2816	021	0	1	09	04	H2816_021_0	6	4		01	7d;16b;				1	60.00	60.00	2		2		
H2816	021	0	1	09	04	H2816_021_0	6	3		01	7a;7g;				1	25.00	25.00	2		2		
H2816	021	0	1	09	04	H2816_021_0	6	2		01	7b;				2			2		1	20	20
H2816	021	0	1	09	04	H2816_021_0	6	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;17b;18a;	9d;14c;18a;	2		2			2		1	20	20
H2816	021	0	1	09	04	H2816_021_0	6	6		11	8a1;8a2;8b1;8b2;8b3;14e;17a;	17a;	2		2			2		1	20	20
H2816	027	0	1	09	04	H2816_027_0	6	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;17b;18a;	9d;14c;18a;	2		2			2		1	20	20
H2816	027	0	1	09	04	H2816_027_0	6	2		01	7b;				2			2		1	20	20
H2816	027	0	1	09	04	H2816_027_0	6	3		01	7a;7g;				1	10.00	10.00	2		2		
H2816	027	0	1	09	04	H2816_027_0	6	4		01	7d;16b;				1	35.00	35.00	2		2		
H2816	027	0	1	09	04	H2816_027_0	6	5		01	10a;				1	300.00	300.00	2		2		
H2816	027	0	1	09	04	H2816_027_0	6	6		11	8a1;8a2;8b1;8b2;8b3;14e;17a;	17a;	2		2			2		1	20	20
H2816	031	0	1	09	04	H2816_031_0	5	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;17b;18a;	9d;14c;18a;	2		2			2		1	20	20
H2816	031	0	1	09	04	H2816_031_0	5	2		01	7b;				2			2		1	20	20
H2816	031	0	1	09	04	H2816_031_0	5	5		01	10a;				1	300.00	300.00	2		2		
H2816	031	0	1	09	04	H2816_031_0	5	4		01	7d;16b;				1	50.00	50.00	2		2		
H2816	031	0	1	09	04	H2816_031_0	5	3		01	7a;7g;				1	20.00	20.00	2		2		
H2816	031	0	1	09	04	H2816_031_0	5	6		11	8a1;8a2;8b1;8b2;8b3;14e;17a;	17a;	2		2			2		1	20	20
H2816	032	0	1	09	04	H2816_032_0	5	3		01	7a;7g;				1	30.00	30.00	2		2		
H2816	032	0	1	09	04	H2816_032_0	5	4		01	7d;16b;				1	60.00	60.00	2		2		
H2816	032	0	1	09	04	H2816_032_0	5	5		01	10a;				1	300.00	300.00	2		2		
H2816	032	0	1	09	04	H2816_032_0	5	6		11	8a1;8a2;8b1;8b2;8b3;14e;17a;	17a;	2		2			2		1	20	20
H2816	032	0	1	09	04	H2816_032_0	5	1		11	3-1;3-2;3-3;5;6;7c;7e;7f;7h;7i;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;17b;18a;	9d;14c;18a;	2		2			2		1	20	20
H2816	032	0	1	09	04	H2816_032_0	5	2		01	7b;				2			2		1	20	20
H2816	801	0	1	09	04	H2816_801_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2816	801	0	1	09	04	H2816_801_0	6	1		01	6;14a;		2		2			2		1	0	0
H2816	802	0	1	09	04	H2816_802_0	6	1		01	6;14a;		2		2			2		1	0	0
H2816	802	0	1	09	04	H2816_802_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2816	803	0	1	09	04	H2816_803_0	6	1		01	6;14a;		2		2			2		1	0	0
H2816	803	0	1	09	04	H2816_803_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2836	801	0	1	04	01	H2836_801_0	4	1		01	6;14a;		2		2			2		1	0	0
H2836	801	0	1	04	01	H2836_801_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2836	802	0	1	04	01	H2836_802_0	4	1		01	6;14a;		2		2			2		1	0	0
H2836	802	0	1	04	01	H2836_802_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2836	803	0	1	04	01	H2836_803_0	4	1		01	6;14a;		2		2			2		1	0	0
H2836	803	0	1	04	01	H2836_803_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2905	001	0	1	04	01	H2905_001_0	2	10	Group 10	01	6;		2		2			2		1	50	50
H2905	001	0	1	04	01	H2905_001_0	2	2	Group 2	11	3-1;3-2;3-3;7b;7c;7d;7e;7f;7h;7i;9c;16b;17a;18a;	7f;18a;	2		1	65.00	65.00	2		2		
H2905	001	0	1	04	01	H2905_001_0	2	11	Group 11	10		18b;	2		1	390.00	450.00	2		2		
H2905	001	0	1	04	01	H2905_001_0	2	12	Group 12	01	8a2;		2		1	19.00	19.00	2		2		
H2905	001	0	1	04	01	H2905_001_0	2	13	Group 13	01	8b3;		2		1	20.00	20.00	2		2		
H2905	001	0	1	04	01	H2905_001_0	2	14	Group 14	01	11a;		2		2			2		1	45	45
H2905	001	0	1	04	01	H2905_001_0	2	1	Group 1	01	7a;		2		1	20.00	20.00	2		2		
H2905	001	0	1	04	01	H2905_001_0	2	3	Group 3	11	8a1;8b1;8b2;9a;9b;11b;11c;14d;14e;17b;	14b;	2		2			2		1	30	30
H2905	001	0	1	04	01	H2905_001_0	2	4	Group 4	01	12;15;		2		2			2		1	20	20
H2905	001	0	1	04	01	H2905_001_0	2	5	Group 5	01	7g;		2		1	20.00	65.00	2		2		
H2905	001	0	1	04	01	H2905_001_0	2	6	Group 6	01	5;		2		1	75.00	75.00	2		2		
H2905	001	0	1	04	01	H2905_001_0	2	7	Group 7	11	9d;	9d;14c;	2		1	0.00	0.00	2		2		
H2905	001	0	1	04	01	H2905_001_0	2	9	Group 9	01	10a;		2		1	200.00	200.00	2		1	30	30
H2905	001	0	1	04	01	H2905_001_0	2	8	Group 8	01	14a;		2		2			2		1	0	30
H2906	005	0	1	04	01	H2906_005_0	11	2	OON Primary Care Physician Services	01	7a;		2		1	25.00	25.00	2		2		
H2906	005	0	1	04	01	H2906_005_0	11	6	OON Transportation Services	10		10b;	2		2			2		2		
H2906	005	0	1	04	01	H2906_005_0	11	7	OON Chiropractic Services	01	7b;		2		1	40.00	40.00	2		2		
H2906	005	0	1	04	01	H2906_005_0	11	8	OON Preventive Dental	10		16a;	2		2			2		2		
H2906	005	0	1	04	01	H2906_005_0	11	5	OON Supp Education/Welness Programs	10		14c;	2		1	0.00	0.00	2		2		
H2906	005	0	1	04	01	H2906_005_0	11	1	Out-of-Network (OON) Services	01	3-1;3-2;3-3;5;6;7c;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	30	30
H2906	005	0	1	04	01	H2906_005_0	11	4	OON Outpatient Blood Services	10		9d;	2		2			2		1	30	30
H2906	005	0	1	04	01	H2906_005_0	11	3	OON Physician Specialist Services	01	7d;7e;7f;7g;7h;		2		1	65.00	65.00	2		2		
H2906	006	0	1	04	01	H2906_006_0	10	1	Out-of-Network (OON) Services	01	3-1;3-2;3-3;5;6;7c;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	30	30
H2906	006	0	1	04	01	H2906_006_0	10	2	OON Primary Care Physician Services	01	7a;		2		1	35.00	35.00	2		2		
H2906	006	0	1	04	01	H2906_006_0	10	3	OON Physician Specialist Services	01	7d;7e;7f;7g;7h;		2		1	65.00	65.00	2		2		
H2906	006	0	1	04	01	H2906_006_0	10	4	OON Outpatient Blood Services	10		9d;	2		2			2		1	30	30
H2906	006	0	1	04	01	H2906_006_0	10	8	OON Preventive Dental	10		16a;	2		2			2		2		
H2906	006	0	1	04	01	H2906_006_0	10	7	OON Chiropractic Services	01	7b;		2		1	40.00	40.00	2		2		
H2906	006	0	1	04	01	H2906_006_0	10	6	OON Transportation Services	10		10b;	2		2			2		2		
H2906	006	0	1	04	01	H2906_006_0	10	5	OON Supp Education/Welness Programs	10		14c;	2		1	0.00	0.00	2		2		
H2906	007	0	1	04	01	H2906_007_0	7	6	OON Transportation Services	10		10b;	2		2			2		2		
H2906	007	0	1	04	01	H2906_007_0	7	5	OON Supp Education/Welness Programs	10		14c;	2		1	0.00	0.00	2		2		
H2906	007	0	1	04	01	H2906_007_0	7	4	OON Outpatient Blood Services	10		9d;	2		2			2		1	30	30
H2906	007	0	1	04	01	H2906_007_0	7	3	OON Physician Specialist Services	01	7d;7e;7f;7g;7h;		2		1	75.00	75.00	2		2		
H2906	007	0	1	04	01	H2906_007_0	7	2	OON Primary Care Physician Services	01	7a;		2		1	35.00	35.00	2		2		
H2906	007	0	1	04	01	H2906_007_0	7	1	Out-of-Network (OON) Services	01	3-1;3-2;3-3;5;6;7c;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	30	30
H2906	007	0	1	04	01	H2906_007_0	7	7	OON Chiropractic Services	01	7b;		2		1	40.00	40.00	2		2		
H2906	008	0	1	04	01	H2906_008_0	4	3	OON Physician Specialist Services	01	7d;7e;7f;7g;7h;		2		1	75.00	75.00	2		2		
H2906	008	0	1	04	01	H2906_008_0	4	1	Out-of-Network (OON) Services	01	3-1;3-2;3-3;5;6;7c;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	30	30
H2906	008	0	1	04	01	H2906_008_0	4	2	OON Primary Care Physician Services	01	7a;		2		1	35.00	35.00	2		2		
H2906	008	0	1	04	01	H2906_008_0	4	4	OON Outpatient Blood Services	10		9d;	2		2			2		1	30	30
H2906	008	0	1	04	01	H2906_008_0	4	5	OON Supp Education/Welness Programs	10		14c;	2		1	0.00	0.00	2		2		
H2906	008	0	1	04	01	H2906_008_0	4	7	OON Chiropractic Services	01	7b;		2		1	40.00	40.00	2		2		
H2906	008	0	1	04	01	H2906_008_0	4	6	OON Transportation Services	10		10b;	2		2			2		2		
H2906	801	0	1	04	01	H2906_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2906	801	0	1	04	01	H2906_801_0	2	1		01	6;14a;		2		2			2		1	0	0
H2944	004	0	1	09	04	H2944_004_0	4	3		10		13c;14c;	2		2			2		1	50	50
H2944	004	0	1	09	04	H2944_004_0	4	2		01	11a;11c;				2			2		1	30	30
H2944	004	0	1	09	04	H2944_004_0	4	1		11	9d;	9d;13d;14b;	2		1	0.00	0.00	2		2		
H2944	013	0	1	09	04	H2944_013_0	3	4		10		13c;14c;	2		2			2		1	50	50
H2944	013	0	1	09	04	H2944_013_0	3	5		10		13b;	1	15.00	2			2		1	50	50
H2944	013	0	1	09	04	H2944_013_0	3	1		11	8a2;9d;14a;	9d;13d;14b;	2		1	0.00	0.00	2		2		
H2944	013	0	1	09	04	H2944_013_0	3	2		01	11a;				2			2		1	15	15
H2944	013	0	1	09	04	H2944_013_0	3	3		01	11c;				2			2		1	20	20
H2944	078	0	1	09	04	H2944_078_0	3	3		10		13c;14c;	2		2			2		1	50	50
H2944	078	0	1	09	04	H2944_078_0	3	4		10		13b;	1	15.00	2			2		1	50	50
H2944	078	0	1	09	04	H2944_078_0	3	2		01	11a;11c;				2			2		1	20	20
H2944	078	0	1	09	04	H2944_078_0	3	1		11	8a2;9d;14a;	9d;13d;14b;	2		1	0.00	0.00	2		2		
H2944	114	0	1	09	04	H2944_114_0	3	2		01	11a;11c;				2			2		1	20	20
H2944	114	0	1	09	04	H2944_114_0	3	1		11	6;8a2;9d;14a;	9d;13d;14b;	2		1	0.00	0.00	2		2		
H2944	114	0	1	09	04	H2944_114_0	3	3		10		13c;14c;	2		2			2		1	50	50
H2944	114	0	1	09	04	H2944_114_0	3	4		10		13b;	1	15.00	2			2		1	50	50
H2944	124	0	1	09	04	H2944_124_0	3	1		11	9d;14a;	9d;13d;14b;	2		1	0.00	0.00	2		2		
H2944	124	0	1	09	04	H2944_124_0	3	2		01	8a2;				2			2		1	0	0
H2944	124	0	1	09	04	H2944_124_0	3	3		01	11a;11c;				2			2		1	20	20
H2944	124	0	1	09	04	H2944_124_0	3	4		10		13c;14c;	2		2			2		1	50	50
H2944	124	0	1	09	04	H2944_124_0	3	5		10		13b;	1	15.00	2			2		1	50	50
H2944	127	0	1	09	04	H2944_127_0	3	4		10		13c;14c;	2		2			2		1	50	50
H2944	127	0	1	09	04	H2944_127_0	3	3		01	11a;11c;				2			2		1	20	20
H2944	127	0	1	09	04	H2944_127_0	3	2		01	8a2;				2			2		1	0	0
H2944	127	0	1	09	04	H2944_127_0	3	1		11	9d;14a;	9d;13d;14b;	2		1	0.00	0.00	2		2		
H2944	127	0	1	09	04	H2944_127_0	3	5		10		13b;	1	20.00	2			2		1	50	50
H2944	197	0	1	09	04	H2944_197_0	2	2		11	8a2;14a;	14b;	2		2			2		1	0	0
H2944	197	0	1	09	04	H2944_197_0	2	1		11	9d;	9d;13d;	2		1	0.00	0.00	2		2		
H2944	197	0	1	09	04	H2944_197_0	2	3		01	11a;				2			2		1	19	19
H2944	197	0	1	09	04	H2944_197_0	2	4		01	11c;				2			2		1	20	20
H2944	197	0	1	09	04	H2944_197_0	2	5		10		13c;14c;	2		2			2		1	50	50
H2944	197	0	1	09	04	H2944_197_0	2	6		10		13b;	1	20.00	2			2		1	50	50
H2968	001	0	1	04	01	H2968_001_0	7	2	OON - ESRD	01	12;		2		2			2		1	20	20
H2968	001	0	1	04	01	H2968_001_0	7	1	OON Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	17a;18a;	2		2			2		1	40	40
H2968	001	0	1	04	01	H2968_001_0	7	3	OON - Ambulance	01	10a;		2		1	250.00	250.00	2		2		
H2968	001	0	1	04	01	H2968_001_0	7	6	Hearing Aids	10		18b;	1	500.00	2			2		2		
H2968	001	0	1	04	01	H2968_001_0	7	5	OON-14c	10		14c;	1	500.00	2			2		1	0	40
H2968	001	0	1	04	01	H2968_001_0	7	4	OON -Eyewear	10		17b;	1	100.00	1	100.00	100.00	2		2		
H2968	801	0	1	04	01	H2968_801_0	4	1		01	6;14a;		2		2			2		1	0	0
H2968	801	0	1	04	01	H2968_801_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2968	802	0	1	04	01	H2968_802_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H2968	802	0	1	04	01	H2968_802_0	4	1		01	6;14a;		2		2			2		1	0	0
H2968	803	0	1	04	01	H2968_803_0	4	1		01	6;14a;		2		2			2		1	0	0
H2968	803	0	1	04	01	H2968_803_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3206	001	0	1	04	01	H3206_001_0	7	6	0% - 20%	01	8a1;8a2;8b1;8b2;9a;9b;15;		2		2			2		1	0	20
H3206	001	0	1	04	01	H3206_001_0	7	5	10%	01	8b3;		2		2			2		1	10	10
H3206	001	0	1	04	01	H3206_001_0	7	4	150.00	01	10a;		2		1	150.00	150.00	2		2		
H3206	001	0	1	04	01	H3206_001_0	7	3	60.00	11	7b;7d;7f;16b;17a;18a;	13a;17a;18a;	2		1	60.00	60.00	2		2		
H3206	001	0	1	04	01	H3206_001_0	7	2	35.00	11	3-1;3-2;3-3;7a;7c;7g;7i;14a;	3-1;3-2;3-3;14b;14c;	2		1	35.00	35.00	2		2		
H3206	001	0	1	04	01	H3206_001_0	7	1	0.00	11	6;9d;12;14d;	9d;	2		1	0.00	0.00	2		2		
H3206	001	0	1	04	01	H3206_001_0	7	7	25%	01	11a;11b;11c;14e;17b;		2		2			2		1	25	25
H3206	001	0	1	04	01	H3206_001_0	7	8	50%	01	5;7e;7h;9c;		2		2			2		1	50	50
H3206	002	0	1	04	01	H3206_002_0	8	6	0% - 20%	01	8a1;8a2;8b1;8b2;9a;9b;15;		2		2			2		1	0	20
H3206	002	0	1	04	01	H3206_002_0	8	5	10%	01	8b3;		2		2			2		1	10	10
H3206	002	0	1	04	01	H3206_002_0	8	4	150.00	01	10a;		2		1	150.00	150.00	2		2		
H3206	002	0	1	04	01	H3206_002_0	8	3	60.00	11	7b;7d;7f;16b;17a;18a;	13a;17a;18a;	2		1	60.00	60.00	2		2		
H3206	002	0	1	04	01	H3206_002_0	8	2	35.00	11	3-1;3-2;3-3;7a;7c;7g;7i;14a;	3-1;3-2;3-3;14b;14c;	2		1	35.00	35.00	2		2		
H3206	002	0	1	04	01	H3206_002_0	8	1	0.00	11	6;9d;12;14d;	9d;	2		1	0.00	0.00	2		2		
H3206	002	0	1	04	01	H3206_002_0	8	7	25%	01	11a;11b;11c;14e;17b;		2		2			2		1	25	25
H3206	002	0	1	04	01	H3206_002_0	8	8	50%	01	5;7e;7h;9c;		2		2			2		1	50	50
H3206	003	0	1	04	01	H3206_003_0	5	1	0.00	11	6;9d;12;14d;	9d;	2		1	0.00	0.00	2		2		
H3206	003	0	1	04	01	H3206_003_0	5	2	35.00	11	3-1;3-2;3-3;7a;7c;7g;7i;14a;	3-1;3-2;3-3;14b;14c;	2		1	35.00	35.00	2		2		
H3206	003	0	1	04	01	H3206_003_0	5	3	60.00	11	7b;7d;7f;16b;17a;18a;	13a;17a;18a;	2		1	60.00	60.00	2		2		
H3206	003	0	1	04	01	H3206_003_0	5	4	150.00	01	10a;		2		1	150.00	150.00	2		2		
H3206	003	0	1	04	01	H3206_003_0	5	5	10%	01	8b3;		2		2			2		1	10	10
H3206	003	0	1	04	01	H3206_003_0	5	6	0% - 20%	01	8a1;8a2;8b1;8b2;9a;9b;15;		2		2			2		1	0	20
H3206	003	0	1	04	01	H3206_003_0	5	7	25%	01	11a;11b;11c;14e;17b;		2		2			2		1	25	25
H3206	003	0	1	04	01	H3206_003_0	5	8	50%	01	5;7e;7h;9c;		2		2			2		1	50	50
H3206	801	0	1	04	01	H3206_801_0	3	1		01	6;14a;		2		2			2		1	0	0
H3206	801	0	1	04	01	H3206_801_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3206	802	0	1	04	01	H3206_802_0	3	1		01	6;14a;		2		2			2		1	0	0
H3206	802	0	1	04	01	H3206_802_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3206	803	0	1	04	01	H3206_803_0	3	1		01	6;14a;		2		2			2		1	0	0
H3206	803	0	1	04	01	H3206_803_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3335	005	0	1	04	01	H3335_005_0	6	3	Ambulance	01	10a;		2		1	200.00	200.00	2		2		
H3335	005	0	1	04	01	H3335_005_0	6	2	50% Coinsurance	01	5;		2		2			2		1	50	50
H3335	005	0	1	04	01	H3335_005_0	6	10	ESRD	01	12;		2		2			2		1	20	20
H3335	005	0	1	04	01	H3335_005_0	6	1	30% Coinsurance	11	6;7e;7h;8a1;8a2;8b1;8b2;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;	9d;14b;	2		2			2		1	30	30
H3335	005	0	1	04	01	H3335_005_0	6	9	Preventive Dental	10		16a;	2		2			2		2		
H3335	005	0	1	04	01	H3335_005_0	6	5	Preventive Services	01	14a;		2		1	0.00	25.00	2		1	30	30
H3335	005	0	1	04	01	H3335_005_0	6	6	Supplemental Education/Wellness Programs	10		14c;	2		2			2		2		
H3335	005	0	1	04	01	H3335_005_0	6	7	$25 Copayment	01	7a;7b;		2		1	25.00	25.00	2		2		
H3335	005	0	1	04	01	H3335_005_0	6	8	$55 Copayment - Specialist Services	11	3-1;3-2;3-3;7d;7f;7g;8b3;16b;17a;17b;18a;	17a;18a;	2		1	55.00	55.00	2		2		
H3335	005	0	1	04	01	H3335_005_0	6	4	PT/OT/ST	01	7c;7i;		2		1	50.00	50.00	2		2		
H3335	006	0	1	04	01	H3335_006_0	6	4	Specialist	11	3-1;3-2;3-3;7c;7d;7f;7g;7i;8b3;16b;17a;17b;18a;	17a;18a;	2		1	50.00	50.00	2		2		
H3335	006	0	1	04	01	H3335_006_0	6	3	Ambulance	01	10a;		2		1	150.00	150.00	2		2		
H3335	006	0	1	04	01	H3335_006_0	6	2	50% Coinsurance	01	5;		2		2			2		1	50	50
H3335	006	0	1	04	01	H3335_006_0	6	1	30% Coinsurance	11	6;7e;7h;8a1;8a2;8b1;8b2;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;	9d;14b;	2		2			2		1	30	30
H3335	006	0	1	04	01	H3335_006_0	6	5	Preventive Services	01	14a;		2		1	0.00	20.00	2		1	30	30
H3335	006	0	1	04	01	H3335_006_0	6	9	ESRD	01	12;		2		2			2		1	20	20
H3335	006	0	1	04	01	H3335_006_0	6	8	Preventive Dental	10		16a;	2		2			2		2		
H3335	006	0	1	04	01	H3335_006_0	6	7	$20 Copayment	01	7a;7b;		2		1	20.00	20.00	2		2		
H3335	006	0	1	04	01	H3335_006_0	6	6	Supplemental Education/Wellness Programs	10		14c;	2		2			2		2		
H3335	014	0	1	04	01	H3335_014_0	6	1	30% Coinsurance	11	6;7e;7h;8a1;8a2;8b1;8b2;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;	9d;14b;	2		2			2		1	30	30
H3335	014	0	1	04	01	H3335_014_0	6	10	ESRD	01	12;		2		2			2		1	20	20
H3335	014	0	1	04	01	H3335_014_0	6	2	50% Coinsurance	01	5;		2		2			2		1	50	50
H3335	014	0	1	04	01	H3335_014_0	6	3	Ambulance	01	10a;		2		1	200.00	200.00	2		2		
H3335	014	0	1	04	01	H3335_014_0	6	9	Preventive Dental	10		16a;	2		2			2		2		
H3335	014	0	1	04	01	H3335_014_0	6	8	$55 Copayment - Specialist Services	11	3-1;3-2;3-3;7d;7f;7g;8b3;16b;17a;17b;18a;	17a;18a;	2		1	55.00	55.00	2		2		
H3335	014	0	1	04	01	H3335_014_0	6	7	$25 Copayment	01	7a;7b;		2		1	25.00	25.00	2		2		
H3335	014	0	1	04	01	H3335_014_0	6	6	Supplemental Education/Wellness Programs	10		14c;	2		2			2		2		
H3335	014	0	1	04	01	H3335_014_0	6	5	Preventive Services	01	14a;		2		1	0.00	25.00	2		1	30	30
H3335	014	0	1	04	01	H3335_014_0	6	4	PT/OT/ST	01	7c;7i;		2		1	50.00	50.00	2		2		
H3335	015	0	1	04	01	H3335_015_0	6	1	30% Coinsurance	11	6;7e;7h;8a1;8a2;8b1;8b2;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;	9d;14b;	2		2			2		1	30	30
H3335	015	0	1	04	01	H3335_015_0	6	2	50% Coinsurance	01	5;		2		2			2		1	50	50
H3335	015	0	1	04	01	H3335_015_0	6	9	ESRD	01	12;		2		2			2		1	20	20
H3335	015	0	1	04	01	H3335_015_0	6	8	Preventive Dental	10		16a;	2		2			2		2		
H3335	015	0	1	04	01	H3335_015_0	6	7	$20 Copayment	01	7a;7b;		2		1	20.00	20.00	2		2		
H3335	015	0	1	04	01	H3335_015_0	6	6	Supplemental Education/Wellness Programs	10		14c;	2		2			2		2		
H3335	015	0	1	04	01	H3335_015_0	6	5	Preventive Services	01	14a;		2		1	0.00	20.00	2		1	30	30
H3335	015	0	1	04	01	H3335_015_0	6	4	Specialist	11	3-1;3-2;3-3;7c;7d;7f;7g;7i;8b3;16b;17a;17b;18a;	17a;18a;	2		1	50.00	50.00	2		2		
H3335	015	0	1	04	01	H3335_015_0	6	3	Ambulance	01	10a;		2		1	150.00	150.00	2		2		
H3335	018	0	1	04	01	H3335_018_0	5	1	30% Coinsurance	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	30	30
H3335	018	0	1	04	01	H3335_018_0	5	5	ESRD	01	12;		2		2			2		1	20	20
H3335	018	0	1	04	01	H3335_018_0	5	4	$0 Copayment	10		14c;	2		2			2		2		
H3335	018	0	1	04	01	H3335_018_0	5	3	Ambulance	01	10a;		2		1	250.00	250.00	2		2		
H3335	018	0	1	04	01	H3335_018_0	5	2	50% Coinsurance	01	5;		2		2			2		1	50	50
H3335	038	0	1	04	01	H3335_038_0	6	6	Supplemental Education/Wellness Programs	10		14c;	2		2			2		2		
H3335	038	0	1	04	01	H3335_038_0	6	5	Preventive Services	01	14a;		2		1	0.00	25.00	2		1	30	30
H3335	038	0	1	04	01	H3335_038_0	6	4	PT/OT/ST	01	7c;7i;		2		1	50.00	50.00	2		2		
H3335	038	0	1	04	01	H3335_038_0	6	3	Ambulance	01	10a;		2		1	250.00	250.00	2		2		
H3335	038	0	1	04	01	H3335_038_0	6	2	50% Coinsurance	01	5;		2		2			2		1	50	50
H3335	038	0	1	04	01	H3335_038_0	6	1	30% Coinsurance	11	6;7e;7h;8a1;8a2;8b1;8b2;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;	9d;14b;17a;	2		2			2		1	30	30
H3335	038	0	1	04	01	H3335_038_0	6	7	$25 Copayment	01	7a;7b;		2		1	25.00	25.00	2		2		
H3335	038	0	1	04	01	H3335_038_0	6	9	ESRD	01	12;		2		2			2		1	20	20
H3335	038	0	1	04	01	H3335_038_0	6	8	$60 Copayment - Specialist Services	11	3-1;3-2;3-3;7d;7f;7g;8b3;16b;17a;17b;18a;	18a;	2		1	60.00	60.00	2		2		
H3335	041	0	1	04	01	H3335_041_0	5	4	$0 Copayment	10		14c;	2		2			2		2		
H3335	041	0	1	04	01	H3335_041_0	5	3	Ambulance	01	10a;		2		1	200.00	200.00	2		2		
H3335	041	0	1	04	01	H3335_041_0	5	5	ESRD	01	12;		2		2			2		1	20	20
H3335	041	0	1	04	01	H3335_041_0	5	2	50% Coinsurance	01	5;		2		2			2		1	50	50
H3335	041	0	1	04	01	H3335_041_0	5	1	30% Coinsurance	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	30	30
H3335	043	0	1	04	01	H3335_043_0	4	1	30% Coinsurance	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	30	30
H3335	043	0	1	04	01	H3335_043_0	4	5	ESRD	01	12;		2		2			2		1	20	20
H3335	043	0	1	04	01	H3335_043_0	4	3	Ambulance	01	10a;		2		1	200.00	200.00	2		2		
H3335	043	0	1	04	01	H3335_043_0	4	4	$0 Copayment	10		14c;	2		2			2		2		
H3335	043	0	1	04	01	H3335_043_0	4	2	50% Coinsurance	01	5;		2		2			2		1	50	50
H3335	044	0	1	04	01	H3335_044_0	5	1	30% Coinsurance	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	30	30
H3335	044	0	1	04	01	H3335_044_0	5	2	50% Coinsurance	01	5;		2		2			2		1	50	50
H3335	044	0	1	04	01	H3335_044_0	5	3	Ambulance	01	10a;		2		1	200.00	200.00	2		2		
H3335	044	0	1	04	01	H3335_044_0	5	4	$0 Copayment	10		14c;	2		2			2		2		
H3335	044	0	1	04	01	H3335_044_0	5	5	ESRD	01	12;		2		2			2		1	20	20
H3335	051	0	1	04	01	H3335_051_0	6	2	50% Coinsurance	01	5;		2		2			2		1	50	50
H3335	051	0	1	04	01	H3335_051_0	6	1	30% Coinsurance	11	6;7e;7h;8a1;8a2;8b1;8b2;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;	9d;14b;	2		2			2		1	30	30
H3335	051	0	1	04	01	H3335_051_0	6	9	ESRD	01	12;		2		2			2		1	20	20
H3335	051	0	1	04	01	H3335_051_0	6	8	$60 Copayment - Specialist Services	11	3-1;3-2;3-3;7d;7f;7g;8b3;16b;17a;17b;18a;	17a;18a;	2		1	60.00	60.00	2		2		
H3335	051	0	1	04	01	H3335_051_0	6	5	Preventive Services	01	14a;		2		1	0.00	25.00	2		1	30	30
H3335	051	0	1	04	01	H3335_051_0	6	6	Supplemental Education/Wellness Programs	10		14c;	2		2			2		2		
H3335	051	0	1	04	01	H3335_051_0	6	3	Ambulance	01	10a;		2		1	250.00	250.00	2		2		
H3335	051	0	1	04	01	H3335_051_0	6	4	PT/OT/ST	01	7c;7i;		2		1	50.00	50.00	2		2		
H3335	051	0	1	04	01	H3335_051_0	6	7	$25 Copayment	01	7a;7b;		2		1	25.00	25.00	2		2		
H3335	053	0	1	04	01	H3335_053_0	7	7	$25 Copayment	01	7a;7b;		2		1	25.00	25.00	2		2		
H3335	053	0	1	04	01	H3335_053_0	7	9	ESRD	01	12;		2		2			2		1	20	20
H3335	053	0	1	04	01	H3335_053_0	7	8	$60 Copayment - Specialist Services	11	3-1;3-2;3-3;7d;7f;7g;8b3;16b;17a;17b;18a;	18a;	2		1	60.00	60.00	2		2		
H3335	053	0	1	04	01	H3335_053_0	7	6	Supplemental Education/Wellness Programs	10		14c;	2		2			2		2		
H3335	053	0	1	04	01	H3335_053_0	7	5	Preventive Services	01	14a;		2		1	0.00	25.00	2		1	30	30
H3335	053	0	1	04	01	H3335_053_0	7	4	PT/OT/ST	01	7c;7i;		2		1	50.00	50.00	2		2		
H3335	053	0	1	04	01	H3335_053_0	7	3	Ambulance	01	10a;		2		1	250.00	250.00	2		2		
H3335	053	0	1	04	01	H3335_053_0	7	2	50% Coinsurance	01	5;		2		2			2		1	50	50
H3335	053	0	1	04	01	H3335_053_0	7	1	30% Coinsurance	11	6;7e;7h;8a1;8a2;8b1;8b2;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;	9d;14b;17a;	2		2			2		1	30	30
H3335	054	0	1	04	01	H3335_054_0	6	6	Supplemental Education/Wellness Programs	10		14c;	2		2			2		2		
H3335	054	0	1	04	01	H3335_054_0	6	9	ESRD	01	12;		2		2			2		1	20	20
H3335	054	0	1	04	01	H3335_054_0	6	8	$60 Copayment - Specialist Services	11	3-1;3-2;3-3;7d;7f;7g;8b3;16b;17a;17b;18a;	18a;	2		1	60.00	60.00	2		2		
H3335	054	0	1	04	01	H3335_054_0	6	7	$25 Copayment	01	7a;7b;		2		1	25.00	25.00	2		2		
H3335	054	0	1	04	01	H3335_054_0	6	5	Preventive Services	01	14a;		2		1	0.00	25.00	2		1	30	30
H3335	054	0	1	04	01	H3335_054_0	6	2	50% Coinsurance	01	5;		2		2			2		1	50	50
H3335	054	0	1	04	01	H3335_054_0	6	3	Ambulance	01	10a;		2		1	250.00	250.00	2		2		
H3335	054	0	1	04	01	H3335_054_0	6	4	PT/OT/ST	01	7c;7i;		2		1	50.00	50.00	2		2		
H3335	054	0	1	04	01	H3335_054_0	6	1	30% Coinsurance	11	6;7e;7h;8a1;8a2;8b1;8b2;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;	9d;14b;17a;	2		2			2		1	30	30
H3335	801	0	1	04	01	H3335_801_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3335	801	0	1	04	01	H3335_801_0	4	1		01	6;14a;		2		2			2		1	0	0
H3335	811	0	1	04	01	H3335_811_0	5	1		01	6;14a;		2		2			2		1	0	0
H3335	811	0	1	04	01	H3335_811_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3335	813	0	1	04	01	H3335_813_0	4	3	20% Coinsurance	01	5;7e;7h;9c;		2		2			2		1	20	20
H3335	813	0	1	04	01	H3335_813_0	4	1	20% Coinsurance	01	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3335	813	0	1	04	01	H3335_813_0	4	2	$0 Copayment	01	6;		2		1	0.00	0.00	2		2		
H3335	819	0	1	04	01	H3335_819_0	5	1		01	6;14a;		2		2			2		1	0	0
H3335	819	0	1	04	01	H3335_819_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3335	820	0	1	04	01	H3335_820_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3335	820	0	1	04	01	H3335_820_0	5	1		01	6;14a;		2		2			2		1	0	0
H3335	822	0	1	04	01	H3335_822_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3335	822	0	1	04	01	H3335_822_0	4	1		01	6;14a;		2		2			2		1	0	0
H3342	019	0	1	04	01	H3342_019_0	9	2	$50 Copay	01	7a;7g;		2		1	50.00	50.00	2		2		
H3342	019	0	1	04	01	H3342_019_0	9	1	$0 Copay	11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H3342	019	0	1	04	01	H3342_019_0	9	4	40% Coinsurance	11	3-1;3-2;3-3;5;6;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;	14b;	2		2			2		1	40	40
H3342	019	0	1	04	01	H3342_019_0	9	5	Ambulance	01	10a;		2		1	295.00	295.00	2		1	20	20
H3342	019	0	1	04	01	H3342_019_0	9	3	$75 Copay	01	7b;7c;7d;7e;7f;7h;7i;		2		1	75.00	75.00	2		2		
H3342	019	0	1	04	01	H3342_019_0	9	7	$0 Copay	10		14c;	1	95.00	1	0.00	0.00	2		2		
H3342	019	0	1	04	01	H3342_019_0	9	6	20% Coinsurance	11	12;16b;	16a;	2		2			2		1	20	20
H3342	808	0	1	04	01	H3342_808_0	4	1		01	6;14a;		2		2			2		1	0	0
H3342	808	0	1	04	01	H3342_808_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3342	809	0	1	04	01	H3342_809_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3342	809	0	1	04	01	H3342_809_0	4	1		01	6;14a;		2		2			2		1	0	0
H3342	810	0	1	04	01	H3342_810_0	4	1		01	6;14a;		2		2			2		1	0	0
H3342	810	0	1	04	01	H3342_810_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3344	005	0	1	04	01	H3344_005_0	7	5	45% coinsurance	01	5;7e;7h;9c;		2		2			2		1	45	45
H3344	005	0	1	04	01	H3344_005_0	7	6	50% coinsurance	11	7b;11a;11b;	16a;	2		2			2		1	50	50
H3344	005	0	1	04	01	H3344_005_0	7	4	30%	11	3-1;3-2;3-3;6;7c;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;11c;14a;14d;14e;15;16b;18a;	9d;15;17a;18a;	2		2			2		1	30	30
H3344	005	0	1	04	01	H3344_005_0	7	3	$200 copay	01	10a;		2		1	200.00	200.00	2		2		
H3344	005	0	1	04	01	H3344_005_0	7	1	$0 Copayment	11	12;17b;	14c;17b;	2		2			2		2		
H3344	005	0	1	04	01	H3344_005_0	7	2	$40 copayment	01	7a;7d;7f;7g;17a;		2		1	40.00	40.00	2		2		
H3344	801	0	1	04	01	H3344_801_0	5	1		01	6;14a;		2		2			2		1	0	0
H3344	801	0	1	04	01	H3344_801_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3344	804	0	1	04	01	H3344_804_0	5	1		01	6;14a;		2		2			2		1	0	0
H3344	804	0	1	04	01	H3344_804_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3404	001	0	1	04	01	H3404_001_0	10	4	Eye Exam OON	10		17a;	2		2			2		1	20	20
H3404	001	0	1	04	01	H3404_001_0	10	3	20% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;15;16b;17a;17b;18a;	9d;	2		2			2		1	20	20
H3404	001	0	1	04	01	H3404_001_0	10	2	$0 Copay	11	14a;14d;14e;	14b;14c;	2		1	0.00	0.00	2		2		
H3404	001	0	1	04	01	H3404_001_0	10	1	$250 Copay	01	10a;		2		1	250.00	250.00	2		2		
H3404	801	0	1	04	01	H3404_801_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3404	801	0	1	04	01	H3404_801_0	3	1		01	6;14a;		2		2			2		1	0	0
H3404	803	0	1	04	01	H3404_803_0	3	1		01	6;14a;		2		2			2		1	0	0
H3404	803	0	1	04	01	H3404_803_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3421	001	0	1	09	04	H3421_001_0	4	3	50	01	3-1;3-2;3-3;7d;7f;7g;				1	50.00	50.00	2		2		
H3421	001	0	1	09	04	H3421_001_0	4	9	0	11	6;9d;14a;14d;14e;	9d;	2		2			2		2		
H3421	001	0	1	09	04	H3421_001_0	4	8	20	01	8b1;8b2;8b3;12;15;				2			2		1	20	20
H3421	001	0	1	09	04	H3421_001_0	4	7	15	01	7a;8a1;				1	15.00	15.00	2		2		
H3421	001	0	1	09	04	H3421_001_0	4	6	50	01	16b;17a;17b;18a;				2			2		1	50	50
H3421	001	0	1	09	04	H3421_001_0	4	5	40	01	7c;7e;7h;7i;				1	40.00	40.00	2		2		
H3421	001	0	1	09	04	H3421_001_0	4	4	10	01	8a2;				1	10.00	10.00	2		2		
H3421	001	0	1	09	04	H3421_001_0	4	2	20	01	7b;				1	20.00	20.00	2		2		
H3421	001	0	1	09	04	H3421_001_0	4	15	23-24	01	11a;11b;11c;				2			2		1	23	24
H3421	001	0	1	09	04	H3421_001_0	4	14	250	01	9a;				1	250.00	250.00	2		2		
H3421	001	0	1	09	04	H3421_001_0	4	13	150	01	9b;				1	150.00	150.00	2		2		
H3421	001	0	1	09	04	H3421_001_0	4	12	50-250	01	9c;				1	50.00	250.00	2		2		
H3421	001	0	1	09	04	H3421_001_0	4	11	200	01	10a;				1	200.00	200.00	2		2		
H3421	001	0	1	09	04	H3421_001_0	4	10	50	10		14c;16a;17a;17b;18a;18b;	2		2			2		1	50	50
H3421	001	0	1	09	04	H3421_001_0	4	1	55	01	5;				1	55.00	55.00	2		2		
H3421	002	0	1	09	04	H3421_002_0	5	2	20	01	7a;7b;				1	20.00	20.00	2		2		
H3421	002	0	1	09	04	H3421_002_0	5	8	20	01	8b1;8b2;8b3;12;15;				2			2		1	20	20
H3421	002	0	1	09	04	H3421_002_0	5	4	10	01	8a2;				1	10.00	10.00	2		2		
H3421	002	0	1	09	04	H3421_002_0	5	5	40	01	7c;7e;7h;7i;				1	40.00	40.00	2		2		
H3421	002	0	1	09	04	H3421_002_0	5	7	15	01	8a1;				1	15.00	15.00	2		2		
H3421	002	0	1	09	04	H3421_002_0	5	6	50	01	16b;17a;17b;18a;				2			2		1	50	50
H3421	002	0	1	09	04	H3421_002_0	5	13	150	01	9b;				1	150.00	150.00	2		2		
H3421	002	0	1	09	04	H3421_002_0	5	12	50-250	01	9c;				1	50.00	250.00	2		2		
H3421	002	0	1	09	04	H3421_002_0	5	11	200	01	10a;				1	200.00	200.00	2		2		
H3421	002	0	1	09	04	H3421_002_0	5	10	50	10		14c;17a;17b;18a;18b;	2		2			2		1	50	50
H3421	002	0	1	09	04	H3421_002_0	5	1	55	01	5;				1	55.00	55.00	2		2		
H3421	002	0	1	09	04	H3421_002_0	5	14	250	01	9a;				1	250.00	250.00	2		2		
H3421	002	0	1	09	04	H3421_002_0	5	15	23-24	01	11a;11b;11c;				2			2		1	23	24
H3421	002	0	1	09	04	H3421_002_0	5	9	0	11	6;9d;14a;14d;14e;	9d;	2		2			2		2		
H3421	002	0	1	09	04	H3421_002_0	5	3	50	01	3-1;3-2;3-3;7d;7f;7g;				1	50.00	50.00	2		2		
H3813	001	0	1	04	01	H3813_001_0	3	2	$35 Copayment	11	3-1;3-2;3-3;5;7c;7d;7f;7i;16b;18a;	17a;	2		1	35.00	35.00	2		2		
H3813	001	0	1	04	01	H3813_001_0	3	1	$0 Copayment	11	6;8a1;8a2;9d;14a;14d;14e;17a;17b;	14c;	2		2			2		2		
H3813	001	0	1	04	01	H3813_001_0	3	9	$20 - $35	01	7g;		2		1	20.00	35.00	2		2		
H3813	001	0	1	04	01	H3813_001_0	3	8	$0 or 20%	01	11c;		2		2			2		1	0	20
H3813	001	0	1	04	01	H3813_001_0	3	3	20% Coinsurance	01	8b1;8b2;8b3;11a;11b;12;15;		2		2			2		1	20	20
H3813	001	0	1	04	01	H3813_001_0	3	6	$100 Copayment	01	10a;		2		1	100.00	100.00	2		2		
H3813	001	0	1	04	01	H3813_001_0	3	5	$20 Copayment	01	7a;7b;		2		1	20.00	20.00	2		2		
H3813	001	0	1	04	01	H3813_001_0	3	4	$20 - $30 Copayment	01	7e;7h;9c;		2		1	20.00	30.00	2		2		
H3813	001	0	1	04	01	H3813_001_0	3	7	$300 Copayment	01	9a;9b;		2		1	300.00	300.00	2		2		
H3813	006	0	1	04	01	H3813_006_0	5	2	20% coinsurance	01	12;		2		2			2		1	20	20
H3813	006	0	1	04	01	H3813_006_0	5	1	zero copay	11	8a1;8a2;9d;14a;14d;14e;17a;17b;	14c;	2		2			2		2		
H3813	006	0	1	04	01	H3813_006_0	5	5	$35 - $50 copayment	01	7g;		2		1	35.00	50.00	2		2		
H3813	006	0	1	04	01	H3813_006_0	5	6	$35.00 copayment	10		17a;	2		1	35.00	35.00	2		2		
H3813	006	0	1	04	01	H3813_006_0	5	7	30% coinsurance	01	6;8b1;8b2;8b3;9a;9b;11a;11b;15;		2		2			2		1	30	30
H3813	006	0	1	04	01	H3813_006_0	5	8	$250 copayment	01	10a;		2		1	250.00	250.00	2		2		
H3813	006	0	1	04	01	H3813_006_0	5	3	$40 copay	01	7a;7b;7e;7h;9c;		2		1	40.00	40.00	2		2		
H3813	006	0	1	04	01	H3813_006_0	5	4	$50 copayment	01	3-1;3-2;3-3;5;7c;7d;7f;7i;16b;18a;		2		1	50.00	50.00	2		2		
H3813	006	0	1	04	01	H3813_006_0	5	9	$0 or 30%	01	11c;		2		2			2		1	0	30
H3813	802	0	1	04	01	H3813_802_0	2	8	$ Diabetic Supplies 10%Therapeutic shoes	01	11c;		2		1	0.00	0.00	2		1	10	10
H3813	802	0	1	04	01	H3813_802_0	2	6	$50 copayment	01	10a;		2		1	50.00	50.00	2		2		
H3813	802	0	1	04	01	H3813_802_0	2	7	$125.00 copayment	01	9a;9b;		2		1	125.00	125.00	2		2		
H3813	802	0	1	04	01	H3813_802_0	2	5	10% coinsurance	01	8b1;8b2;8b3;11a;11b;12;15;		2		2			2		1	10	10
H3813	802	0	1	04	01	H3813_802_0	2	4	$20.00 copayment	11	3-1;3-2;3-3;5;7b;7c;7d;7e;7f;7h;7i;9c;16b;18a;	17a;	2		1	20.00	20.00	2		2		
H3813	802	0	1	04	01	H3813_802_0	2	3	$15 - $20 copayment	01	7g;		2		1	15.00	20.00	2		2		
H3813	802	0	1	04	01	H3813_802_0	2	1	zero copayment	11	6;8a1;8a2;9d;14a;14d;14e;17a;17b;	14c;	2		2			2		2		
H3813	802	0	1	04	01	H3813_802_0	2	2	$15.00 copayment	01	7a;		2		1	15.00	15.00	2		2		
H3817	007	1	1	04	01	H3817_007_1	5	4	30% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;	2		2			2		1	30	30
H3817	007	1	1	04	01	H3817_007_1	5	3	$300 copay	01	10a;		2		1	300.00	300.00	2		2		
H3817	007	1	1	04	01	H3817_007_1	5	2	$40 copay	10		17a;	2		1	40.00	40.00	2		2		
H3817	007	1	1	04	01	H3817_007_1	5	1	$0 copay	10		14c;17b;	2		2			2		2		
H3817	007	1	1	04	01	H3817_007_1	5	5	50% coinsurance	10		16a;	2		2			2		1	50	50
H3817	007	2	1	04	01	H3817_007_2	5	5	50% coinsurance	10		16a;	2		2			2		1	50	50
H3817	007	2	1	04	01	H3817_007_2	5	3	$300 copay	01	10a;		2		1	300.00	300.00	2		2		
H3817	007	2	1	04	01	H3817_007_2	5	4	30% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;	2		2			2		1	30	30
H3817	007	2	1	04	01	H3817_007_2	5	2	$40 copay	10		17a;	2		1	40.00	40.00	2		2		
H3817	007	2	1	04	01	H3817_007_2	5	1	$0 copay	10		14c;17b;	2		2			2		2		
H3817	008	1	1	04	01	H3817_008_1	6	5	50% coinsurance	10		16a;	2		2			2		1	50	50
H3817	008	1	1	04	01	H3817_008_1	6	4	30% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;	2		2			2		1	30	30
H3817	008	1	1	04	01	H3817_008_1	6	3	$300 copay	01	10a;		2		1	300.00	300.00	2		2		
H3817	008	1	1	04	01	H3817_008_1	6	2	$40 copay	10		17a;	2		1	40.00	40.00	2		2		
H3817	008	1	1	04	01	H3817_008_1	6	1	$0 copay	10		14c;17b;	2		2			2		2		
H3817	008	2	1	04	01	H3817_008_2	6	4	30% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;	2		2			2		1	30	30
H3817	008	2	1	04	01	H3817_008_2	6	5	50% coinsurance	10		16a;	2		2			2		1	50	50
H3817	008	2	1	04	01	H3817_008_2	6	3	$300 copay	01	10a;		2		1	300.00	300.00	2		2		
H3817	008	2	1	04	01	H3817_008_2	6	2	$40 copay	10		17a;	2		1	40.00	40.00	2		2		
H3817	008	2	1	04	01	H3817_008_2	6	1	$0 copay	10		14c;17b;	2		2			2		2		
H3817	009	1	1	04	01	H3817_009_1	7	4	30% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;	2		2			2		1	30	30
H3817	009	1	1	04	01	H3817_009_1	7	3	$250 copay	01	10a;		2		1	250.00	250.00	2		2		
H3817	009	1	1	04	01	H3817_009_1	7	2	$25 copay	10		17a;	2		1	25.00	25.00	2		2		
H3817	009	1	1	04	01	H3817_009_1	7	1	$0 copay	10		14c;17b;	2		2			2		2		
H3817	009	1	1	04	01	H3817_009_1	7	6	$599 or $899 copay	10		18b;	2		1	599.00	899.00	2		2		
H3817	009	1	1	04	01	H3817_009_1	7	5	50% coinsurance	10		16a;	2		2			2		1	50	50
H3817	009	2	1	04	01	H3817_009_2	7	6	$599 or $899 copay	10		18b;	2		1	599.00	899.00	2		2		
H3817	009	2	1	04	01	H3817_009_2	7	5	50% coinsurance	10		16a;	2		2			2		1	50	50
H3817	009	2	1	04	01	H3817_009_2	7	2	$25 copay	10		17a;	2		1	25.00	25.00	2		2		
H3817	009	2	1	04	01	H3817_009_2	7	3	$250 copay	01	10a;		2		1	250.00	250.00	2		2		
H3817	009	2	1	04	01	H3817_009_2	7	4	30% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;	2		2			2		1	30	30
H3817	009	2	1	04	01	H3817_009_2	7	1	$0 copay	10		14c;17b;	2		2			2		2		
H3817	801	0	1	04	01	H3817_801_0	5	1		01	6;14a;		2		2			2		1	0	0
H3817	801	0	1	04	01	H3817_801_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3817	802	0	1	04	01	H3817_802_0	5	1		01	6;14a;		2		2			2		1	0	0
H3817	802	0	1	04	01	H3817_802_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3832	007	0	1	04	01	H3832_007_0	9	2	Group 2 - $0	11	9d;14a;14d;14e;17b;	9d;14c;	2		1	0.00	0.00	2		2		
H3832	007	0	1	04	01	H3832_007_0	9	1	Group 1 - 30%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;12;15;16b;17a;18a;	17a;	2		2			2		1	30	30
H3832	007	0	1	04	01	H3832_007_0	9	3	Group 3 - $200	01	10a;		2		1	200.00	200.00	2		2		
H3832	007	0	1	04	01	H3832_007_0	9	4	Group 4 - $0, $100	10		17b;	2		2			2		2		
H3832	008	0	1	04	01	H3832_008_0	7	1	Group 1 - 30%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;12;15;16b;17a;18a;	17a;	2		2			2		1	30	30
H3832	008	0	1	04	01	H3832_008_0	7	2	Group 2 - $0	11	9d;14a;14d;14e;17b;	9d;14c;	2		1	0.00	0.00	2		2		
H3832	008	0	1	04	01	H3832_008_0	7	3	Group 3 - $200	01	10a;		2		1	200.00	200.00	2		2		
H3832	008	0	1	04	01	H3832_008_0	7	4	Group 4 - $0, $100 max	10		17b;	2		2			2		2		
H3832	009	0	1	04	01	H3832_009_0	8	2	Group 2 - $0	11	9d;14a;14d;14e;17b;	9d;14c;	2		1	0.00	0.00	2		2		
H3832	009	0	1	04	01	H3832_009_0	8	1	Group 1 - 30%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;12;15;16b;17a;18a;	17a;	2		2			2		1	30	30
H3832	009	0	1	04	01	H3832_009_0	8	3	Group 3 - $200	01	10a;		2		1	200.00	200.00	2		2		
H3832	009	0	1	04	01	H3832_009_0	8	4	Group 4 - $0, $70 max	10		17b;	2		2			2		2		
H3832	010	0	1	04	01	H3832_010_0	8	1	Group 1 - 30%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;12;15;16b;17a;18a;	17a;	2		2			2		1	30	30
H3832	010	0	1	04	01	H3832_010_0	8	2	Group 2 - $0	11	9d;14a;14d;14e;17b;	9d;14c;	2		1	0.00	0.00	2		2		
H3832	010	0	1	04	01	H3832_010_0	8	3	Group 3 - $200	01	10a;		2		1	200.00	200.00	2		2		
H3832	010	0	1	04	01	H3832_010_0	8	4	Group 4 - $0, $75 max	10		17b;	2		2			2		2		
H3832	011	0	1	04	01	H3832_011_0	11	1	Group 1 - $0	11	14a;	14c;	2		1	0.00	0.00	2		2		
H3832	011	0	1	04	01	H3832_011_0	11	2	Group 2: 30%	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	30	30
H3832	801	0	1	04	01	H3832_801_0	3	1	Group 1 - 0 cost share	11	6;14a;	14c;	2		2			2		1	0	0
H3832	801	0	1	04	01	H3832_801_0	3	2	Group 2	01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3832	802	0	1	04	01	H3832_802_0	3	1		11	6;14a;	14c;	2		2			2		1	0	0
H3832	802	0	1	04	01	H3832_802_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	30	30
H3832	805	0	1	04	01	H3832_805_0	2	1	1 - $0	11	6;14a;	14c;	2		2			2		1	0	0
H3832	805	0	1	04	01	H3832_805_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3832	807	0	1	04	01	H3832_807_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3832	807	0	1	04	01	H3832_807_0	3	1		11	6;14a;	14c;	2		2			2		1	0	0
H3890	001	0	1	04	01	H3890_001_0	10	1	OON - 50% Coinsurance	11	7b;7e;7h;8a1;8a2;8b1;8b2;9a;9b;9c;11a;11b;12;14a;14d;14e;16b;17a;17b;18a;	16a;16b;17a;	2		2			2		1	50	50
H3890	001	0	1	04	01	H3890_001_0	10	2	OON - 30% Coinsurance	01	5;6;7a;7d;7g;8b3;		2		2			2		1	30	30
H3890	001	0	1	04	01	H3890_001_0	10	3	Ambulance Services	01	10a;		2		1	265.00	265.00	2		2		
H3890	001	0	1	04	01	H3890_001_0	10	4	Nurseline + Blood Services	11	9d;	9d;14c;	2		2			2		2		
H3890	001	0	1	04	01	H3890_001_0	10	5	OON - 40% Coinsurace	01	3-1;3-2;3-3;7c;7f;7i;11c;15;		2		2			2		1	40	40
H3890	002	0	1	04	01	H3890_002_0	11	3	Ambulance Services	01	10a;		2		1	215.00	215.00	2		2		
H3890	002	0	1	04	01	H3890_002_0	11	2	OON - 30% Coinsurance	01	3-1;3-2;3-3;6;7a;7b;7c;7d;7f;7g;7i;11c;15;		2		2			2		1	30	30
H3890	002	0	1	04	01	H3890_002_0	11	1	OON - 20% Coinsurance	01	5;8b3;		2		2			2		1	20	20
H3890	002	0	1	04	01	H3890_002_0	11	4	Acupuncture	10		13a;	1	100.00	2			2		2		
H3890	002	0	1	04	01	H3890_002_0	11	9	Vision	10		17a;17b;	2		2			2		1	45	45
H3890	002	0	1	04	01	H3890_002_0	11	8	Blood Services	11	9d;	9d;	2		2			2		2		
H3890	002	0	1	04	01	H3890_002_0	11	7	45% Coinsurance	11	7e;7h;8a1;8a2;8b1;8b2;9a;9b;9c;11a;11b;12;14a;14d;14e;16b;17a;17b;18a;	16a;16b;	2		2			2		1	45	45
H3890	002	0	1	04	01	H3890_002_0	11	6	Fitness and Nurseline	10		14c;	2		2			2		2		
H3890	002	0	1	04	01	H3890_002_0	11	5	Hearing Aids	10		18a;18b;	2		2			2		2		
H3890	801	0	1	04	01	H3890_801_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3890	801	0	1	04	01	H3890_801_0	6	1		01	6;14a;		2		2			2		1	0	0
H3890	802	0	1	04	01	H3890_802_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3890	802	0	1	04	01	H3890_802_0	6	1		01	6;14a;		2		2			2		1	0	0
H3890	803	0	1	04	01	H3890_803_0	6	1		01	6;14a;		2		2			2		1	0	0
H3890	803	0	1	04	01	H3890_803_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3909	001	0	1	04	01	H3909_001_0	4	4	OON Supplemental Benefits	10		14c;	2		2			2		2		
H3909	001	0	1	04	01	H3909_001_0	4	3	OON Ambulance	01	10a;		2		1	150.00	150.00	2		2		
H3909	001	0	1	04	01	H3909_001_0	4	2	OON Hearing Aid	10		18b;	2		1	699.00	999.00	2		2		
H3909	001	0	1	04	01	H3909_001_0	4	1	30% OON	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	7b;7f;9d;14b;18a;	2		2			2		1	30	30
H3909	001	0	1	04	01	H3909_001_0	4	5	OON Dialysis	01	12;		2		2			2		1	20	20
H3909	007	0	1	04	01	H3909_007_0	1	4	OON Supplemental Benefits	10		14c;	2		2			2		2		
H3909	007	0	1	04	01	H3909_007_0	1	3	OON Ambulance	01	10a;		2		1	150.00	150.00	2		2		
H3909	007	0	1	04	01	H3909_007_0	1	2	OON Hearing Aid	10		18b;	2		1	699.00	999.00	2		2		
H3909	007	0	1	04	01	H3909_007_0	1	1	30% OON	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	7b;7f;9d;14b;18a;	2		2			2		1	30	30
H3909	007	0	1	04	01	H3909_007_0	1	5	OON Dialysis	01	12;		2		2			2		1	20	20
H3909	009	0	1	04	01	H3909_009_0	4	1	30% OON	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	7b;7f;9d;14b;18a;	2		2			2		1	30	30
H3909	009	0	1	04	01	H3909_009_0	4	2	OON Hearing Aid	10		18b;	2		1	699.00	999.00	2		2		
H3909	009	0	1	04	01	H3909_009_0	4	3	OON Ambulance	01	10a;		2		1	150.00	150.00	2		2		
H3909	009	0	1	04	01	H3909_009_0	4	4	OON Supplemental Benefits	10		14c;	2		2			2		2		
H3909	009	0	1	04	01	H3909_009_0	4	5	OON Dialysis	01	12;		2		2			2		1	20	20
H3909	801	0	1	04	01	H3909_801_0	2	1		01	6;14a;		2		2			2		1	0	0
H3909	801	0	1	04	01	H3909_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3909	802	0	1	04	01	H3909_802_0	2	1		01	6;14a;		2		2			2		1	0	0
H3909	802	0	1	04	01	H3909_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3916	001	0	1	04	01	H3916_001_0	9	3	Ambulance	01	10a;		2		1	100.00	100.00	2		1	30	30
H3916	001	0	1	04	01	H3916_001_0	9	2	Preventive Services and Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2		2		
H3916	001	0	1	04	01	H3916_001_0	9	10	Routine Eye Exam	10		17a;	2		1	40.00	40.00	2		2		
H3916	001	0	1	04	01	H3916_001_0	9	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;16b;18a;	7b;7f;9d;18a;	2		2			2		1	30	30
H3916	001	0	1	04	01	H3916_001_0	9	9	End Stage Renal and Part B Drugs	01	12;15;		2		2			2		1	0	30
H3916	001	0	1	04	01	H3916_001_0	9	5	Fitness Benefit	10		14c;	2		2			1	500.00	1	50	50
H3916	001	0	1	04	01	H3916_001_0	9	6	Primary Care Physician	01	7a;		2		1	10.00	10.00	2		2		
H3916	001	0	1	04	01	H3916_001_0	9	7	Specialist and NonRoutine Eye Exam	01	7d;17a;		2		1	40.00	40.00	2		2		
H3916	001	0	1	04	01	H3916_001_0	9	8	Hearing Aids	10		18b;	2		1	699.00	999.00	2		2		
H3916	001	0	1	04	01	H3916_001_0	9	4	Transportation and Preventive Dental	10		10b;16a;	2		2			2		1	50	50
H3916	002	0	1	04	01	H3916_002_0	8	3	Ambulance	01	10a;		2		1	100.00	100.00	2		1	30	30
H3916	002	0	1	04	01	H3916_002_0	8	2	Preventive Services and Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2		2		
H3916	002	0	1	04	01	H3916_002_0	8	10	Routine Eye Exam	10		17a;	2		1	40.00	40.00	2		2		
H3916	002	0	1	04	01	H3916_002_0	8	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;16b;18a;	7b;7f;9d;18a;	2		2			2		1	30	30
H3916	002	0	1	04	01	H3916_002_0	8	4	Transportation and Preventive Dental	10		10b;16a;	2		2			2		1	50	50
H3916	002	0	1	04	01	H3916_002_0	8	9	End Stage Renal and Part B Drugs	01	12;15;		2		2			2		1	0	30
H3916	002	0	1	04	01	H3916_002_0	8	8	Hearing Aids	10		18b;	2		1	699.00	999.00	2		2		
H3916	002	0	1	04	01	H3916_002_0	8	7	Specialist and NonRoutine Eye Exam	01	7d;17a;		2		1	40.00	40.00	2		2		
H3916	002	0	1	04	01	H3916_002_0	8	6	Primary Care Physician	01	7a;		2		1	10.00	10.00	2		2		
H3916	002	0	1	04	01	H3916_002_0	8	5	Fitness Benefit	10		14c;	2		2			1	500.00	1	50	50
H3916	005	0	1	04	01	H3916_005_0	8	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;16b;18a;	7b;7f;9d;18a;	2		2			2		1	30	30
H3916	005	0	1	04	01	H3916_005_0	8	10	Routine Eye Exam	10		17a;	2		1	40.00	40.00	2		2		
H3916	005	0	1	04	01	H3916_005_0	8	2	Preventive Services and Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2		2		
H3916	005	0	1	04	01	H3916_005_0	8	3	Ambulance	01	10a;		2		1	100.00	100.00	2		1	30	30
H3916	005	0	1	04	01	H3916_005_0	8	9		01	12;15;		2		2			2		1	0	30
H3916	005	0	1	04	01	H3916_005_0	8	7	Specialist and NonRoutine Eye Exam	01	7d;17a;		2		1	40.00	40.00	2		2		
H3916	005	0	1	04	01	H3916_005_0	8	6	Primary Care Physician	01	7a;		2		1	30.00	30.00	2		2		
H3916	005	0	1	04	01	H3916_005_0	8	5	Fitness Benefit	10		14c;	2		2			1	500.00	1	50	50
H3916	005	0	1	04	01	H3916_005_0	8	4	Transportation and Preventive Dental	10		10b;16a;	2		2			2		1	50	50
H3916	005	0	1	04	01	H3916_005_0	8	8	Hearing Aids	10		18b;	2		1	499.00	799.00	2		2		
H3916	012	0	1	04	01	H3916_012_0	6	3	Ambulance	01	10a;		2		1	125.00	125.00	2		1	30	30
H3916	012	0	1	04	01	H3916_012_0	6	2	Preventive Services and Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2		2		
H3916	012	0	1	04	01	H3916_012_0	6	9	End Stage Renal and Part B Drugs	01	12;15;		2		2			2		1	0	30
H3916	012	0	1	04	01	H3916_012_0	6	8	Hearing Aids	10		18b;	2		1	699.00	999.00	2		2		
H3916	012	0	1	04	01	H3916_012_0	6	7	Specialist and NonRoutine Eye Exam	01	7d;17a;		2		1	45.00	45.00	2		2		
H3916	012	0	1	04	01	H3916_012_0	6	6	Primary Care Physician	01	7a;		2		1	30.00	30.00	2		2		
H3916	012	0	1	04	01	H3916_012_0	6	5	Fitness Benefit	10		14c;	2		2			1	500.00	1	50	50
H3916	012	0	1	04	01	H3916_012_0	6	4	Transportation and Preventive Dental	10		10b;16a;	2		2			2		1	50	50
H3916	012	0	1	04	01	H3916_012_0	6	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;16b;18a;	7b;7f;9d;18a;	2		2			2		1	30	30
H3916	012	0	1	04	01	H3916_012_0	6	10	Routine Eye Exam	10		17a;	2		1	40.00	40.00	2		2		
H3916	015	0	1	04	01	H3916_015_0	9	3	Ambulance	01	10a;		2		1	125.00	125.00	2		1	30	30
H3916	015	0	1	04	01	H3916_015_0	9	2	Preventive Services and Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2		2		
H3916	015	0	1	04	01	H3916_015_0	9	5	Fitness Benefit	10		14c;	2		2			1	500.00	1	50	50
H3916	015	0	1	04	01	H3916_015_0	9	6	Primary Care Physician	01	7a;		2		1	30.00	30.00	2		2		
H3916	015	0	1	04	01	H3916_015_0	9	4	Transportation and Preventive Dental	10		10b;16a;	2		2			2		1	50	50
H3916	015	0	1	04	01	H3916_015_0	9	8	Hearing Aids	10		18b;	2		1	699.00	999.00	2		2		
H3916	015	0	1	04	01	H3916_015_0	9	9	End Stage Renal and Part B Drugs	01	12;15;		2		2			2		1	0	30
H3916	015	0	1	04	01	H3916_015_0	9	10	Routine Eye Exam	10		17a;	2		1	40.00	40.00	2		2		
H3916	015	0	1	04	01	H3916_015_0	9	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;16b;18a;	7b;7f;9d;18a;	2		2			2		1	30	30
H3916	015	0	1	04	01	H3916_015_0	9	7	Specialist and NonRoutine Eye Exam	01	7d;17a;		2		1	45.00	45.00	2		2		
H3916	018	0	1	04	01	H3916_018_0	9	3	Ambulance	01	10a;		2		1	150.00	150.00	2		1	30	30
H3916	018	0	1	04	01	H3916_018_0	9	2	Preventive Services and Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2		2		
H3916	018	0	1	04	01	H3916_018_0	9	10	Routine Eye Exam	10		17a;	2		1	40.00	40.00	2		2		
H3916	018	0	1	04	01	H3916_018_0	9	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;16b;18a;	7b;7f;9d;18a;	2		2			2		1	30	30
H3916	018	0	1	04	01	H3916_018_0	9	9	End Stage Renal and Part B Drugs	01	12;15;		2		2			2		1	0	30
H3916	018	0	1	04	01	H3916_018_0	9	8	Hearing Aids	10		18b;	2		1	699.00	999.00	2		2		
H3916	018	0	1	04	01	H3916_018_0	9	7	Specialist and NonRoutine Eye Exam	01	7d;17a;		2		1	50.00	50.00	2		2		
H3916	018	0	1	04	01	H3916_018_0	9	4	Transportation and Preventive Dental	10		10b;16a;	2		2			2		1	50	50
H3916	018	0	1	04	01	H3916_018_0	9	5	Fitness Benefit	10		14c;	2		2			1	500.00	1	50	50
H3916	018	0	1	04	01	H3916_018_0	9	6	Primary Care Physician	01	7a;		2		1	30.00	30.00	2		2		
H3916	022	0	1	04	01	H3916_022_0	9	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;16b;18a;	7b;7f;9d;18a;	2		2			2		1	30	30
H3916	022	0	1	04	01	H3916_022_0	9	10	Routine Eye Exam	10		17a;	2		1	40.00	40.00	2		2		
H3916	022	0	1	04	01	H3916_022_0	9	9	End Stage Renal and Part B Drugs	01	12;15;		2		2			2		1	0	30
H3916	022	0	1	04	01	H3916_022_0	9	8	Hearing Aids	10		18b;	2		1	699.00	999.00	2		2		
H3916	022	0	1	04	01	H3916_022_0	9	7	Specialist and NonRoutine Eye Exam	01	7d;17a;		2		1	45.00	45.00	2		2		
H3916	022	0	1	04	01	H3916_022_0	9	6	Primary Care Physician	01	7a;		2		1	20.00	20.00	2		2		
H3916	022	0	1	04	01	H3916_022_0	9	5	Fitness Benefit	10		14c;	2		2			1	500.00	1	50	50
H3916	022	0	1	04	01	H3916_022_0	9	4	Transportation and Preventive Dental	10		10b;16a;	2		2			2		1	50	50
H3916	022	0	1	04	01	H3916_022_0	9	3	Ambulance	01	10a;		2		1	150.00	150.00	2		1	30	30
H3916	022	0	1	04	01	H3916_022_0	9	2	Preventive Services and Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2		2		
H3916	024	0	1	04	01	H3916_024_0	9	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;16b;18a;	7b;7f;9d;18a;	2		2			2		1	30	30
H3916	024	0	1	04	01	H3916_024_0	9	8	Hearing Aids	10		18b;	2		1	699.00	999.00	2		2		
H3916	024	0	1	04	01	H3916_024_0	9	7	Specialist and NonRoutine Eye Exam	01	7d;17a;		2		1	45.00	45.00	2		2		
H3916	024	0	1	04	01	H3916_024_0	9	6	Primary Care Physician	01	7a;		2		1	20.00	20.00	2		2		
H3916	024	0	1	04	01	H3916_024_0	9	9	End Stage Renal and Part B Drugs	01	12;15;		2		2			2		1	0	30
H3916	024	0	1	04	01	H3916_024_0	9	4	Transportation and Preventive Dental	10		10b;16a;	2		2			2		1	50	50
H3916	024	0	1	04	01	H3916_024_0	9	3	Ambulance	01	10a;		2		1	150.00	150.00	2		1	30	30
H3916	024	0	1	04	01	H3916_024_0	9	2	Preventive Services and Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2		2		
H3916	024	0	1	04	01	H3916_024_0	9	10	Routine Eye Exam	10		17a;	2		1	40.00	40.00	2		2		
H3916	024	0	1	04	01	H3916_024_0	9	5	Fitness Benefit	10		14c;	2		2			1	500.00	1	50	50
H3916	032	0	1	04	01	H3916_032_0	9	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;16b;18a;	7b;7f;9d;18a;	2		2			2		1	30	30
H3916	032	0	1	04	01	H3916_032_0	9	10	Routine Eye Exam	10		17a;	2		1	40.00	40.00	2		2		
H3916	032	0	1	04	01	H3916_032_0	9	2	Preventive Services and Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2		2		
H3916	032	0	1	04	01	H3916_032_0	9	3	Ambulance	01	10a;		2		1	200.00	200.00	2		1	30	30
H3916	032	0	1	04	01	H3916_032_0	9	9	End Stage Renal and Part B Drugs	01	12;15;		2		2			2		1	0	30
H3916	032	0	1	04	01	H3916_032_0	9	5	Fitness Benefit	10		14c;	2		2			1	500.00	1	50	50
H3916	032	0	1	04	01	H3916_032_0	9	6	Primary Care Physician	01	7a;		2		1	20.00	20.00	2		2		
H3916	032	0	1	04	01	H3916_032_0	9	7	Specialist and NonRoutine Eye Exam	01	7d;17a;		2		1	45.00	45.00	2		2		
H3916	032	0	1	04	01	H3916_032_0	9	8	Hearing Aids	10		18b;	2		1	699.00	999.00	2		2		
H3916	032	0	1	04	01	H3916_032_0	9	4	Transportation and Preventive Dental	10		10b;16a;	2		2			2		1	50	50
H3916	033	0	1	04	01	H3916_033_0	9	5	Fitness Benefit	10		14c;	2		2			1	500.00	1	50	50
H3916	033	0	1	04	01	H3916_033_0	9	6	Primary Care Physician	01	7a;		2		1	20.00	20.00	2		2		
H3916	033	0	1	04	01	H3916_033_0	9	7	Specialist and NonRoutine Eye Exam	01	7d;17a;		2		1	45.00	45.00	2		2		
H3916	033	0	1	04	01	H3916_033_0	9	8	Hearing Aids	10		18b;	2		1	699.00	999.00	2		2		
H3916	033	0	1	04	01	H3916_033_0	9	9	End Stage Renal and Part B Drugs	01	12;15;		2		2			2		1	0	30
H3916	033	0	1	04	01	H3916_033_0	9	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;16b;18a;	7b;7f;9d;18a;	2		2			2		1	30	30
H3916	033	0	1	04	01	H3916_033_0	9	10	Routine Eye Exam	10		17a;	2		1	40.00	40.00	2		2		
H3916	033	0	1	04	01	H3916_033_0	9	2	Preventive Services and Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2		2		
H3916	033	0	1	04	01	H3916_033_0	9	3	Ambulance	01	10a;		2		1	200.00	200.00	2		1	30	30
H3916	033	0	1	04	01	H3916_033_0	9	4	Transportation and Preventive Dental	10		10b;16a;	2		2			2		1	50	50
H3916	801	0	1	04	01	H3916_801_0	4	1		01	6;14a;		2		2			2		1	0	0
H3916	801	0	1	04	01	H3916_801_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3916	802	0	1	04	01	H3916_802_0	4	1		01	6;14a;		2		2			2		1	0	0
H3916	802	0	1	04	01	H3916_802_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3916	804	0	1	04	01	H3916_804_0	4	1		01	6;14a;		2		2			2		1	0	0
H3916	804	0	1	04	01	H3916_804_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3923	013	0	1	04	01	H3923_013_0	8	1	OON Medical Benefits	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14c;17b;	2		2			2		1	30	30
H3923	013	0	1	04	01	H3923_013_0	8	2	OON Routine Eye Exam	10		17a;	2		2			2		1	50	50
H3923	017	0	1	04	01	H3923_017_0	8	2	OON Preventive Dental	10		16a;	2		2			2		1	50	50
H3923	017	0	1	04	01	H3923_017_0	8	3	OON Routine Eye Exams	10		17a;	2		2			2		1	50	50
H3923	017	0	1	04	01	H3923_017_0	8	1	OON Medical Benefits	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14c;17b;18a;18b;	2		2			2		1	30	30
H3923	801	0	1	04	01	H3923_801_0	4	1		01	6;14a;		2		2			2		1	0	0
H3923	801	0	1	04	01	H3923_801_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3923	802	0	1	04	01	H3923_802_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3923	802	0	1	04	01	H3923_802_0	3	1		01	6;14a;		2		2			2		1	0	0
H3923	803	0	1	04	01	H3923_803_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H3923	803	0	1	04	01	H3923_803_0	3	1		01	6;14a;		2		2			2		1	0	0
H3924	059	3	1	04	01	H3924_059_3	6	7	Specialist Copayment	01	7c;7d;7f;7i;16b;17a;18a;		2		1	25.00	25.00	2		2		
H3924	059	3	1	04	01	H3924_059_3	6	8	Partial Hospitalization	01	5;		2		1	55.00	55.00	2		2		
H3924	059	3	1	04	01	H3924_059_3	6	6	$20 Copayment	01	7b;8a1;8a2;8b3;		2		1	20.00	20.00	2		2		
H3924	059	3	1	04	01	H3924_059_3	6	5	Mental Health, Psych, Substance Abuse	01	7e;7h;9c;		2		1	10.00	25.00	2		2		
H3924	059	3	1	04	01	H3924_059_3	6	4	Cardiac and Pulmonary Therapy $10 Copay	01	3-1;3-2;3-3;		2		1	10.00	10.00	2		2		
H3924	059	3	1	04	01	H3924_059_3	6	3	$5 Copay PCP and Annual Routine Physical	11	7a;	14b;	2		1	5.00	5.00	2		2		
H3924	059	3	1	04	01	H3924_059_3	6	2	Out of Network $0 Copay	11	6;7g;9d;14a;14d;14e;17b;	7f;	2		2			2		2		
H3924	059	3	1	04	01	H3924_059_3	6	14	Therapeutic Radiation Services	01	8b2;		2		1	25.00	60.00	2		2		
H3924	059	3	1	04	01	H3924_059_3	6	13	Diagnostic Radiological Services	01	8b1;		2		1	25.00	175.00	2		2		
H3924	059	3	1	04	01	H3924_059_3	6	12	Diabetic Supplies	01	11c;		2		2			2		1	0	20
H3924	059	3	1	04	01	H3924_059_3	6	11	20% Coinsurance Benefits	01	11a;11b;12;15;		2		2			2		1	20	20
H3924	059	3	1	04	01	H3924_059_3	6	9	Ambulance	01	10a;		2		1	200.00	200.00	2		2		
H3924	059	3	1	04	01	H3924_059_3	6	1	Out of Network $0 benefits	10		14c;	1	90.00	2			2		2		
H3924	059	3	1	04	01	H3924_059_3	6	10	Outpatient Surgery and ASC	01	9a;9b;		2		1	225.00	225.00	2		2		
H3924	059	4	1	04	01	H3924_059_4	6	14	Therapeutic Radiation Services	01	8b2;		2		1	25.00	60.00	2		2		
H3924	059	4	1	04	01	H3924_059_4	6	2	Out of Network $0 Copay	11	6;7g;9d;14a;14d;14e;17b;	7f;	2		2			2		2		
H3924	059	4	1	04	01	H3924_059_4	6	3	$5 Copay PCP and Annual Routine Physical	11	7a;	14b;	2		1	5.00	5.00	2		2		
H3924	059	4	1	04	01	H3924_059_4	6	4	Cardiac and Pulmonary Therapy $10 Copay	01	3-1;3-2;3-3;		2		1	10.00	10.00	2		2		
H3924	059	4	1	04	01	H3924_059_4	6	5	Mental Health, Psych, Substance Abuse	01	7e;7h;9c;		2		1	10.00	25.00	2		2		
H3924	059	4	1	04	01	H3924_059_4	6	6	$20 Copayment	01	7b;8a1;8a2;8b3;		2		1	20.00	20.00	2		2		
H3924	059	4	1	04	01	H3924_059_4	6	7	Specialist Copayment	01	7c;7d;7f;7i;16b;17a;18a;		2		1	25.00	25.00	2		2		
H3924	059	4	1	04	01	H3924_059_4	6	8	Partial Hospitalization	01	5;		2		1	55.00	55.00	2		2		
H3924	059	4	1	04	01	H3924_059_4	6	9	Ambulance	01	10a;		2		1	200.00	200.00	2		2		
H3924	059	4	1	04	01	H3924_059_4	6	1	Out of Network $0 benefits	10		14c;	1	90.00	2			2		2		
H3924	059	4	1	04	01	H3924_059_4	6	10	Outpatient Surgery and ASC	01	9a;9b;		2		1	225.00	225.00	2		2		
H3924	059	4	1	04	01	H3924_059_4	6	11	20% Coinsurance Benefits	01	11a;11b;12;15;		2		2			2		1	20	20
H3924	059	4	1	04	01	H3924_059_4	6	12	Diabetic Supplies	01	11c;		2		2			2		1	0	20
H3924	059	4	1	04	01	H3924_059_4	6	13	Diagnostic Radiological Services	01	8b1;		2		1	25.00	175.00	2		2		
H3924	059	6	1	04	01	H3924_059_6	6	1	Out of Network $0 benefits	10		14c;	1	90.00	2			2		2		
H3924	059	6	1	04	01	H3924_059_6	6	10	Outpatient Surgery and ASC	01	9a;9b;		2		1	225.00	225.00	2		2		
H3924	059	6	1	04	01	H3924_059_6	6	9	Ambulance	01	10a;		2		1	200.00	200.00	2		2		
H3924	059	6	1	04	01	H3924_059_6	6	8	Partial Hospitalization	01	5;		2		1	55.00	55.00	2		2		
H3924	059	6	1	04	01	H3924_059_6	6	7	Specialist Copayment	01	7c;7d;7f;7i;16b;17a;18a;		2		1	25.00	25.00	2		2		
H3924	059	6	1	04	01	H3924_059_6	6	6	$20 Copayment	01	7b;8a1;8a2;8b3;		2		1	20.00	20.00	2		2		
H3924	059	6	1	04	01	H3924_059_6	6	5	Mental Health, Psych, Substance Abuse	01	7e;7h;9c;		2		1	10.00	25.00	2		2		
H3924	059	6	1	04	01	H3924_059_6	6	4	Cardiac and Pulmonary Therapy $10 Copay	01	3-1;3-2;3-3;		2		1	10.00	10.00	2		2		
H3924	059	6	1	04	01	H3924_059_6	6	3	$5 Copay PCP and Annual Routine Physical	11	7a;	14b;	2		1	5.00	5.00	2		2		
H3924	059	6	1	04	01	H3924_059_6	6	2	Out of Network $0 Copay	11	6;7g;9d;14a;14d;14e;17b;	7f;	2		2			2		2		
H3924	059	6	1	04	01	H3924_059_6	6	14	Therapeutic Radiation Services	01	8b2;		2		1	25.00	60.00	2		2		
H3924	059	6	1	04	01	H3924_059_6	6	13	Diagnostic Radiological Services	01	8b1;		2		1	25.00	175.00	2		2		
H3924	059	6	1	04	01	H3924_059_6	6	12	Diabetic Supplies	01	11c;		2		2			2		1	0	20
H3924	059	6	1	04	01	H3924_059_6	6	11	20% Coinsurance Benefits	01	11a;11b;12;15;		2		2			2		1	20	20
H3924	059	7	1	04	01	H3924_059_7	6	1	Out of Network $0 benefits	10		14c;	1	90.00	2			2		2		
H3924	059	7	1	04	01	H3924_059_7	6	8	Partial Hospitalization	01	5;		2		1	55.00	55.00	2		2		
H3924	059	7	1	04	01	H3924_059_7	6	7	Specialist Copayment	01	7c;7d;7f;7i;16b;17a;18a;		2		1	25.00	25.00	2		2		
H3924	059	7	1	04	01	H3924_059_7	6	6	$20 Copayment	01	7b;8a1;8a2;8b3;		2		1	20.00	20.00	2		2		
H3924	059	7	1	04	01	H3924_059_7	6	5	Mental Health, Psych, Substance Abuse	01	7e;7h;9c;		2		1	10.00	25.00	2		2		
H3924	059	7	1	04	01	H3924_059_7	6	4	Cardiac and Pulmonary Therapy $10 Copay	01	3-1;3-2;3-3;		2		1	10.00	10.00	2		2		
H3924	059	7	1	04	01	H3924_059_7	6	9	Ambulance	01	10a;		2		1	200.00	200.00	2		2		
H3924	059	7	1	04	01	H3924_059_7	6	2	Out of Network $0 Copay	11	6;7g;9d;14a;14d;14e;17b;	7f;	2		2			2		2		
H3924	059	7	1	04	01	H3924_059_7	6	14	Therapeutic Radiation Services	01	8b2;		2		1	25.00	60.00	2		2		
H3924	059	7	1	04	01	H3924_059_7	6	13	Diagnostic Radiological Services	01	8b1;		2		1	25.00	175.00	2		2		
H3924	059	7	1	04	01	H3924_059_7	6	12	Diabetic Supplies	01	11c;		2		2			2		1	0	20
H3924	059	7	1	04	01	H3924_059_7	6	11	20% Coinsurance Benefits	01	11a;11b;12;15;		2		2			2		1	20	20
H3924	059	7	1	04	01	H3924_059_7	6	10	Outpatient Surgery and ASC	01	9a;9b;		2		1	225.00	225.00	2		2		
H3924	059	7	1	04	01	H3924_059_7	6	3	$5 Copay PCP and Annual Routine Physical	11	7a;	14b;	2		1	5.00	5.00	2		2		
H3924	059	8	1	04	01	H3924_059_8	6	1	Out of Network $0 benefits	10		14c;	1	90.00	2			2		2		
H3924	059	8	1	04	01	H3924_059_8	6	10	Outpatient Surgery and ASC	01	9a;9b;		2		1	225.00	225.00	2		2		
H3924	059	8	1	04	01	H3924_059_8	6	11	20% Coinsurance Benefits	01	11a;11b;12;15;		2		2			2		1	20	20
H3924	059	8	1	04	01	H3924_059_8	6	12	Diabetic Supplies	01	11c;		2		2			2		1	0	20
H3924	059	8	1	04	01	H3924_059_8	6	13	Diagnostic Radiological Services	01	8b1;		2		1	25.00	175.00	2		2		
H3924	059	8	1	04	01	H3924_059_8	6	14	Therapeutic Radiation Services	01	8b2;		2		1	25.00	60.00	2		2		
H3924	059	8	1	04	01	H3924_059_8	6	2	Out of Network $0 Copay	11	6;7g;9d;14a;14d;14e;17b;	7f;	2		2			2		2		
H3924	059	8	1	04	01	H3924_059_8	6	3	$5 Copay PCP and Annual Routine Physical	11	7a;	14b;	2		1	5.00	5.00	2		2		
H3924	059	8	1	04	01	H3924_059_8	6	4	Cardiac and Pulmonary Therapy $10 Copay	01	3-1;3-2;3-3;		2		1	10.00	10.00	2		2		
H3924	059	8	1	04	01	H3924_059_8	6	5	Mental Health, Psych, Substance Abuse	01	7e;7h;9c;		2		1	10.00	25.00	2		2		
H3924	059	8	1	04	01	H3924_059_8	6	6	$20 Copayment	01	7b;8a1;8a2;8b3;		2		1	20.00	20.00	2		2		
H3924	059	8	1	04	01	H3924_059_8	6	7	Specialist Copayment	01	7c;7d;7f;7i;16b;17a;18a;		2		1	25.00	25.00	2		2		
H3924	059	8	1	04	01	H3924_059_8	6	8	Partial Hospitalization	01	5;		2		1	55.00	55.00	2		2		
H3924	059	8	1	04	01	H3924_059_8	6	9	Ambulance	01	10a;		2		1	200.00	200.00	2		2		
H3924	059	9	1	04	01	H3924_059_9	6	1	Out of Network $0 benefits	10		14c;	1	90.00	2			2		2		
H3924	059	9	1	04	01	H3924_059_9	6	10	Outpatient Surgery and ASC	01	9a;9b;		2		1	225.00	225.00	2		2		
H3924	059	9	1	04	01	H3924_059_9	6	11	20% Coinsurance Benefits	01	11a;11b;12;15;		2		2			2		1	20	20
H3924	059	9	1	04	01	H3924_059_9	6	12	Diabetic Supplies	01	11c;		2		2			2		1	0	20
H3924	059	9	1	04	01	H3924_059_9	6	13	Diagnostic Radiological Services	01	8b1;		2		1	25.00	175.00	2		2		
H3924	059	9	1	04	01	H3924_059_9	6	14	Therapeutic Radiation Services	01	8b2;		2		1	25.00	60.00	2		2		
H3924	059	9	1	04	01	H3924_059_9	6	9	Ambulance	01	10a;		2		1	200.00	200.00	2		2		
H3924	059	9	1	04	01	H3924_059_9	6	3	$5 Copay PCP and Annual Routine Physical	11	7a;	14b;	2		1	5.00	5.00	2		2		
H3924	059	9	1	04	01	H3924_059_9	6	4	Cardiac and Pulmonary Therapy $10 Copay	01	3-1;3-2;3-3;		2		1	10.00	10.00	2		2		
H3924	059	9	1	04	01	H3924_059_9	6	5	Mental Health, Psych, Substance Abuse	01	7e;7h;9c;		2		1	10.00	25.00	2		2		
H3924	059	9	1	04	01	H3924_059_9	6	6	$20 Copayment	01	7b;8a1;8a2;8b3;		2		1	20.00	20.00	2		2		
H3924	059	9	1	04	01	H3924_059_9	6	7	Specialist Copayment	01	7c;7d;7f;7i;16b;17a;18a;		2		1	25.00	25.00	2		2		
H3924	059	9	1	04	01	H3924_059_9	6	8	Partial Hospitalization	01	5;		2		1	55.00	55.00	2		2		
H3924	059	9	1	04	01	H3924_059_9	6	2	Out of Network $0 Copay	11	6;7g;9d;14a;14d;14e;17b;	7f;	2		2			2		2		
H3924	060	3	1	04	01	H3924_060_3	6	8	Outpatient Surgery and ASC	01	9a;9b;		2		1	325.00	325.00	2		2		
H3924	060	3	1	04	01	H3924_060_3	6	9	Medicare covered $10 copayment	01	3-1;3-2;3-3;		2		1	10.00	10.00	2		2		
H3924	060	3	1	04	01	H3924_060_3	6	6	Annual Physical Exam	11	7a;	14b;	2		1	5.00	5.00	2		2		
H3924	060	3	1	04	01	H3924_060_3	6	5	Nurseline $0 Copayment	10		14c;	1	90.00	2			2		2		
H3924	060	3	1	04	01	H3924_060_3	6	4	Diabetic supplies and services	01	11c;		2		2			2		1	0	20
H3924	060	3	1	04	01	H3924_060_3	6	3	Out of network $190.00 copayment	01	10a;		2		1	190.00	190.00	2		2		
H3924	060	3	1	04	01	H3924_060_3	6	2	Medicare benefits with a 20% coinsurance	01	11a;11b;12;15;		2		2			2		1	20	20
H3924	060	3	1	04	01	H3924_060_3	6	15	partial hospitalization	01	5;		2		1	55.00	55.00	2		2		
H3924	060	3	1	04	01	H3924_060_3	6	14	Therapeutic radiology	01	8b2;		2		1	35.00	60.00	2		2		
H3924	060	3	1	04	01	H3924_060_3	6	13	Diagnostic radiology	01	8b1;		2		1	35.00	260.00	2		2		
H3924	060	3	1	04	01	H3924_060_3	6	12	$25 lab/xray	01	8a1;8a2;8b3;		2		1	25.00	25.00	2		2		
H3924	060	3	1	04	01	H3924_060_3	6	11	Mental health/sub abuse	01	7e;7h;9c;		2		1	10.00	25.00	2		2		
H3924	060	3	1	04	01	H3924_060_3	6	10	$20 copayment	01	7b;		2		1	20.00	20.00	2		2		
H3924	060	3	1	04	01	H3924_060_3	6	1	Out of Network $0 Copay Benefits	11	6;7g;9d;14a;14d;14e;17b;	7f;	2		2			2		2		
H3924	060	3	1	04	01	H3924_060_3	6	7	Specialist Services	01	7c;7d;7f;7i;16b;17a;18a;		2		1	40.00	40.00	2		2		
H3924	060	4	1	04	01	H3924_060_4	6	8	Outpatient Surgery and ASC	01	9a;9b;		2		1	325.00	325.00	2		2		
H3924	060	4	1	04	01	H3924_060_4	6	7	Specialist Services	01	7c;7d;7f;7i;16b;17a;18a;		2		1	40.00	40.00	2		2		
H3924	060	4	1	04	01	H3924_060_4	6	6	Annual Physical Exam	11	7a;	14b;	2		1	5.00	5.00	2		2		
H3924	060	4	1	04	01	H3924_060_4	6	5	Nurseline $0 Copayment	10		14c;	1	90.00	2			2		2		
H3924	060	4	1	04	01	H3924_060_4	6	4	Diabetic supplies and services	01	11c;		2		2			2		1	0	20
H3924	060	4	1	04	01	H3924_060_4	6	3	Out of network $190.00 copayment	01	10a;		2		1	190.00	190.00	2		2		
H3924	060	4	1	04	01	H3924_060_4	6	2	Medicare benefits with a 20% coinsurance	01	11a;11b;12;15;		2		2			2		1	20	20
H3924	060	4	1	04	01	H3924_060_4	6	15	partial hospitalization	01	5;		2		1	55.00	55.00	2		2		
H3924	060	4	1	04	01	H3924_060_4	6	14	Therapeutic radiology	01	8b2;		2		1	35.00	60.00	2		2		
H3924	060	4	1	04	01	H3924_060_4	6	13	Diagnostic radiology	01	8b1;		2		1	35.00	260.00	2		2		
H3924	060	4	1	04	01	H3924_060_4	6	12	$25 lab/xray	01	8a1;8a2;8b3;		2		1	25.00	25.00	2		2		
H3924	060	4	1	04	01	H3924_060_4	6	11	Mental health/sub abuse	01	7e;7h;9c;		2		1	10.00	25.00	2		2		
H3924	060	4	1	04	01	H3924_060_4	6	10	$20 copayment	01	7b;		2		1	20.00	20.00	2		2		
H3924	060	4	1	04	01	H3924_060_4	6	1	Out of Network $0 Copay Benefits	11	6;7g;9d;14a;14d;14e;17b;	7f;	2		2			2		2		
H3924	060	4	1	04	01	H3924_060_4	6	9	Medicare covered $10 copayment	01	3-1;3-2;3-3;		2		1	10.00	10.00	2		2		
H3924	060	6	1	04	01	H3924_060_6	6	1	Out of Network $0 Copay Benefits	11	6;7g;9d;14a;14d;14e;17b;	7f;	2		2			2		2		
H3924	060	6	1	04	01	H3924_060_6	6	10	$20 copayment	01	7b;		2		1	20.00	20.00	2		2		
H3924	060	6	1	04	01	H3924_060_6	6	9	Medicare covered $10 copayment	01	3-1;3-2;3-3;		2		1	10.00	10.00	2		2		
H3924	060	6	1	04	01	H3924_060_6	6	8	Outpatient Surgery and ASC	01	9a;9b;		2		1	325.00	325.00	2		2		
H3924	060	6	1	04	01	H3924_060_6	6	7	Specialist Services	01	7c;7d;7f;7i;16b;17a;18a;		2		1	40.00	40.00	2		2		
H3924	060	6	1	04	01	H3924_060_6	6	6	Annual Physical Exam	11	7a;	14b;	2		1	5.00	5.00	2		2		
H3924	060	6	1	04	01	H3924_060_6	6	5	Nurseline $0 Copayment	10		14c;	1	90.00	2			2		2		
H3924	060	6	1	04	01	H3924_060_6	6	4	Diabetic supplies and services	01	11c;		2		2			2		1	0	20
H3924	060	6	1	04	01	H3924_060_6	6	3	Out of network $190.00 copayment	01	10a;		2		1	190.00	190.00	2		2		
H3924	060	6	1	04	01	H3924_060_6	6	2	Medicare benefits with a 20% coinsurance	01	11a;11b;12;15;		2		2			2		1	20	20
H3924	060	6	1	04	01	H3924_060_6	6	15	partial hospitalization	01	5;		2		1	55.00	55.00	2		2		
H3924	060	6	1	04	01	H3924_060_6	6	14	Therapeutic radiology	01	8b2;		2		1	35.00	60.00	2		2		
H3924	060	6	1	04	01	H3924_060_6	6	13	Diagnostic radiology	01	8b1;		2		1	35.00	260.00	2		2		
H3924	060	6	1	04	01	H3924_060_6	6	12	$25 lab/xray	01	8a1;8a2;8b3;		2		1	25.00	25.00	2		2		
H3924	060	6	1	04	01	H3924_060_6	6	11	Mental health/sub abuse	01	7e;7h;9c;		2		1	10.00	25.00	2		2		
H3924	060	7	1	04	01	H3924_060_7	6	1	Out of Network $0 Copay Benefits	11	6;7g;9d;14a;14d;14e;17b;	7f;	2		2			2		2		
H3924	060	7	1	04	01	H3924_060_7	6	9	Medicare covered $10 copayment	01	3-1;3-2;3-3;		2		1	10.00	10.00	2		2		
H3924	060	7	1	04	01	H3924_060_7	6	7	Specialist Services	01	7c;7d;7f;7i;16b;17a;18a;		2		1	40.00	40.00	2		2		
H3924	060	7	1	04	01	H3924_060_7	6	6	Annual Physical Exam	11	7a;	14b;	2		1	5.00	5.00	2		2		
H3924	060	7	1	04	01	H3924_060_7	6	5	Nurseline $0 Copayment	10		14c;	1	90.00	2			2		2		
H3924	060	7	1	04	01	H3924_060_7	6	4	Diabetic supplies and services	01	11c;		2		2			2		1	0	20
H3924	060	7	1	04	01	H3924_060_7	6	3	Out of network $190.00 copayment	01	10a;		2		1	190.00	190.00	2		2		
H3924	060	7	1	04	01	H3924_060_7	6	2	Medicare benefits with a 20% coinsurance	01	11a;11b;12;15;		2		2			2		1	20	20
H3924	060	7	1	04	01	H3924_060_7	6	15	partial hospitalization	01	5;		2		1	55.00	55.00	2		2		
H3924	060	7	1	04	01	H3924_060_7	6	14	Therapeutic radiology	01	8b2;		2		1	35.00	60.00	2		2		
H3924	060	7	1	04	01	H3924_060_7	6	13	Diagnostic radiology	01	8b1;		2		1	35.00	260.00	2		2		
H3924	060	7	1	04	01	H3924_060_7	6	12	$25 lab/xray	01	8a1;8a2;8b3;		2		1	25.00	25.00	2		2		
H3924	060	7	1	04	01	H3924_060_7	6	11	Mental health/sub abuse	01	7e;7h;9c;		2		1	10.00	25.00	2		2		
H3924	060	7	1	04	01	H3924_060_7	6	10	$20 copayment	01	7b;		2		1	20.00	20.00	2		2		
H3924	060	7	1	04	01	H3924_060_7	6	8	Outpatient Surgery and ASC	01	9a;9b;		2		1	325.00	325.00	2		2		
H3924	060	8	1	04	01	H3924_060_8	6	15	partial hospitalization	01	5;		2		1	55.00	55.00	2		2		
H3924	060	8	1	04	01	H3924_060_8	6	2	Medicare benefits with a 20% coinsurance	01	11a;11b;12;15;		2		2			2		1	20	20
H3924	060	8	1	04	01	H3924_060_8	6	3	Out of network $190.00 copayment	01	10a;		2		1	190.00	190.00	2		2		
H3924	060	8	1	04	01	H3924_060_8	6	4	Diabetic supplies and services	01	11c;		2		2			2		1	0	20
H3924	060	8	1	04	01	H3924_060_8	6	5	Nurseline $0 Copayment	10		14c;	1	90.00	2			2		2		
H3924	060	8	1	04	01	H3924_060_8	6	6	Annual Physical Exam	11	7a;	14b;	2		1	5.00	5.00	2		2		
H3924	060	8	1	04	01	H3924_060_8	6	7	Specialist Services	01	7c;7d;7f;7i;16b;17a;18a;		2		1	40.00	40.00	2		2		
H3924	060	8	1	04	01	H3924_060_8	6	8	Outpatient Surgery and ASC	01	9a;9b;		2		1	325.00	325.00	2		2		
H3924	060	8	1	04	01	H3924_060_8	6	9	Medicare covered $10 copayment	01	3-1;3-2;3-3;		2		1	10.00	10.00	2		2		
H3924	060	8	1	04	01	H3924_060_8	6	1	Out of Network $0 Copay Benefits	11	6;7g;9d;14a;14d;14e;17b;	7f;	2		2			2		2		
H3924	060	8	1	04	01	H3924_060_8	6	10	$20 copayment	01	7b;		2		1	20.00	20.00	2		2		
H3924	060	8	1	04	01	H3924_060_8	6	11	Mental health/sub abuse	01	7e;7h;9c;		2		1	10.00	25.00	2		2		
H3924	060	8	1	04	01	H3924_060_8	6	12	$25 lab/xray	01	8a1;8a2;8b3;		2		1	25.00	25.00	2		2		
H3924	060	8	1	04	01	H3924_060_8	6	13	Diagnostic radiology	01	8b1;		2		1	35.00	260.00	2		2		
H3924	060	8	1	04	01	H3924_060_8	6	14	Therapeutic radiology	01	8b2;		2		1	35.00	60.00	2		2		
H3924	060	9	1	04	01	H3924_060_9	6	1	Out of Network $0 Copay Benefits	11	6;7g;9d;14a;14d;14e;17b;	7f;	2		2			2		2		
H3924	060	9	1	04	01	H3924_060_9	6	9	Medicare covered $10 copayment	01	3-1;3-2;3-3;		2		1	10.00	10.00	2		2		
H3924	060	9	1	04	01	H3924_060_9	6	11	Mental health/sub abuse	01	7e;7h;9c;		2		1	10.00	25.00	2		2		
H3924	060	9	1	04	01	H3924_060_9	6	12	$25 lab/xray	01	8a1;8a2;8b3;		2		1	25.00	25.00	2		2		
H3924	060	9	1	04	01	H3924_060_9	6	13	Diagnostic radiology	01	8b1;		2		1	35.00	260.00	2		2		
H3924	060	9	1	04	01	H3924_060_9	6	14	Therapeutic radiology	01	8b2;		2		1	35.00	60.00	2		2		
H3924	060	9	1	04	01	H3924_060_9	6	15	partial hospitalization	01	5;		2		1	55.00	55.00	2		2		
H3924	060	9	1	04	01	H3924_060_9	6	2	Medicare benefits with a 20% coinsurance	01	11a;11b;12;15;		2		2			2		1	20	20
H3924	060	9	1	04	01	H3924_060_9	6	3	Out of network $190.00 copayment	01	10a;		2		1	190.00	190.00	2		2		
H3924	060	9	1	04	01	H3924_060_9	6	4	Diabetic supplies and services	01	11c;		2		2			2		1	0	20
H3924	060	9	1	04	01	H3924_060_9	6	5	Nurseline $0 Copayment	10		14c;	1	90.00	2			2		2		
H3924	060	9	1	04	01	H3924_060_9	6	6	Annual Physical Exam	11	7a;	14b;	2		1	5.00	5.00	2		2		
H3924	060	9	1	04	01	H3924_060_9	6	7	Specialist Services	01	7c;7d;7f;7i;16b;17a;18a;		2		1	40.00	40.00	2		2		
H3924	060	9	1	04	01	H3924_060_9	6	8	Outpatient Surgery and ASC	01	9a;9b;		2		1	325.00	325.00	2		2		
H3924	060	9	1	04	01	H3924_060_9	6	10	$20 copayment	01	7b;		2		1	20.00	20.00	2		2		
H4005	001	0	1	04	01	H4005_001_0	7	2	Group 2	11	3-1;3-2;3-3;7b;7c;7e;7f;7i;9c;14e;16b;	7b;7f;16b;	2		2			2		1	25	25
H4005	001	0	1	04	01	H4005_001_0	7	1	Group 1	11	5;6;7a;7d;7g;7h;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;10a;11b;11c;15;17a;18a;	9d;16a;17a;18a;	2		2			2		1	20	20
H4005	001	0	1	04	01	H4005_001_0	7	3	Group 3	10		14c;	1	25.00	2			2		2		
H4005	001	0	1	04	01	H4005_001_0	7	4	Group 4	01	11a;		2		2			2		1	30	30
H4005	001	0	1	04	01	H4005_001_0	7	5		11	12;14a;14d;17b;	10b;13b;17b;18b;	2		2			2		2		
H4005	004	0	1	04	01	H4005_004_0	10	2	Group 2	11	3-1;3-2;3-3;7b;7c;7e;7f;7i;9c;14e;16b;	7b;7f;13a;16b;	2		2			2		1	25	25
H4005	004	0	1	04	01	H4005_004_0	10	1	Group 1	11	5;6;7a;7d;7g;7h;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;10a;11c;15;17a;18a;	9d;15;16a;17a;18a;	2		2			2		1	20	20
H4005	004	0	1	04	01	H4005_004_0	10	3	Group 3	10		14c;	1	25.00	2			2		2		
H4005	004	0	1	04	01	H4005_004_0	10	5	Group 5	11	12;14a;14d;17b;	10b;13b;17b;18b;	2		2			2		2		
H4005	004	0	1	04	01	H4005_004_0	10	4	Group 4	01	11a;11b;		2		2			2		1	30	30
H4005	006	0	1	04	01	H4005_006_0	9	1	Group 1	11	5;6;7a;7d;7g;7h;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;10a;11c;15;17a;18a;	9d;15;16a;17a;18a;	2		2			2		1	20	20
H4005	006	0	1	04	01	H4005_006_0	9	2	Group 2	11	3-1;3-2;3-3;7b;7c;7e;7f;7i;9c;14e;16b;	7b;7f;13a;16b;	2		2			2		1	25	25
H4005	006	0	1	04	01	H4005_006_0	9	4	Group 4	01	11a;11b;		2		2			2		1	30	30
H4005	006	0	1	04	01	H4005_006_0	9	3	Group 3	10		14c;	1	25.00	2			2		2		
H4005	006	0	1	04	01	H4005_006_0	9	5	Group 5	11	12;14a;14d;17b;	10b;13b;17b;18b;	2		2			2		2		
H4005	801	0	1	04	01	H4005_801_0	6	1		01	6;14a;		2		2			2		1	0	0
H4005	801	0	1	04	01	H4005_801_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H4005	802	0	1	04	01	H4005_802_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H4005	802	0	1	04	01	H4005_802_0	5	1		01	6;14a;		2		2			2		1	0	0
H4005	804	0	1	04	01	H4005_804_0	5	1		01	6;14a;		2		2			2		1	0	0
H4005	804	0	1	04	01	H4005_804_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H4005	807	0	1	04	01	H4005_807_0	6	1		01	6;14a;		2		2			2		1	0	0
H4005	807	0	1	04	01	H4005_807_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H4011	010	0	1	04	01	H4011_010_0	6	2	50% coinsurance Group	01	5;7e;7h;9c;		2		2			2		1	50	50
H4011	010	0	1	04	01	H4011_010_0	6	1	20% coinsurance Group	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;10a;11a;11b;11c;12;14a;15;16b;17a;17b;18a;	7b;7f;9d;14c;16a;17a;18a;	2		2			2		1	20	20
H4011	010	0	1	04	01	H4011_010_0	6	3	50% Coinsurance With Max	10		17b;	2		2			2		1	50	50
H4011	010	0	1	04	01	H4011_010_0	6	5	0% Coinsurance Group	11	14d;14e;	13b;	2		2			2		2		
H4011	010	0	1	04	01	H4011_010_0	6	4	$O coinsurance Group with limits	10		18b;	2		2			2		2		
H4011	801	0	1	04	01	H4011_801_0	6	1		01	6;14a;		2		2			2		1	0	0
H4011	801	0	1	04	01	H4011_801_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H4011	803	0	1	04	01	H4011_803_0	5	1		01	6;14a;		2		2			2		1	0	0
H4011	803	0	1	04	01	H4011_803_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H4011	809	0	1	04	01	H4011_809_0	5	1		01	6;14a;		2		2			2		1	0	0
H4011	809	0	1	04	01	H4011_809_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H4036	008	0	1	04	01	H4036_008_0	10	2	20%	11	8b2;12;	16a;18a;	2		2			2		1	20	20
H4036	008	0	1	04	01	H4036_008_0	10	3	Ambulance	01	10a;		2		1	275.00	275.00	2		1	20	20
H4036	008	0	1	04	01	H4036_008_0	10	4	Diag/Rad	01	8a1;8b1;8b3;		2		2			2		1	35	35
H4036	008	0	1	04	01	H4036_008_0	10	5	PCP	01	7a;7g;		2		1	40.00	40.00	2		2		
H4036	008	0	1	04	01	H4036_008_0	10	6	SPEC	11	7b;7c;7d;7e;7f;7h;7i;	14b;	2		1	60.00	60.00	2		2		
H4036	008	0	1	04	01	H4036_008_0	10	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;		2		2			2		1	40	40
H4036	008	0	1	04	01	H4036_008_0	10	8	$20	01	8a2;		2		1	20.00	20.00	2		2		
H4036	008	0	1	04	01	H4036_008_0	10	9	Eligible Supplemental Benefits	10		14c;	1	95.00	1	0.00	0.00	2		2		
H4036	008	0	1	04	01	H4036_008_0	10	1	$0	11	9d;16b;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H4036	009	0	1	04	01	H4036_009_0	10	3	Ambulance	01	10a;		2		1	250.00	250.00	2		1	20	20
H4036	009	0	1	04	01	H4036_009_0	10	2	20%	11	8a2;8b2;12;	16a;18a;	2		2			2		1	20	20
H4036	009	0	1	04	01	H4036_009_0	10	1	$0	11	9d;16b;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H4036	009	0	1	04	01	H4036_009_0	10	4	Diag/Rad	01	8a1;8b1;8b3;		2		2			2		1	35	35
H4036	009	0	1	04	01	H4036_009_0	10	5	PCP	01	7a;7g;		2		1	40.00	40.00	2		2		
H4036	009	0	1	04	01	H4036_009_0	10	6	SPEC	11	7b;7c;7d;7e;7f;7h;7i;	14b;	2		1	60.00	60.00	2		2		
H4036	009	0	1	04	01	H4036_009_0	10	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;		2		2			2		1	40	40
H4036	009	0	1	04	01	H4036_009_0	10	8	Eligible Supplemental Benefits	10		14c;	1	95.00	1	0.00	0.00	2		2		
H4036	010	1	1	04	01	H4036_010_1	10	3	Ambulance	01	10a;		2		1	175.00	175.00	2		1	20	20
H4036	010	1	1	04	01	H4036_010_1	10	2	20%	11	8b2;12;	16a;18a;	2		2			2		1	20	20
H4036	010	1	1	04	01	H4036_010_1	10	1	$0	11	9d;16b;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H4036	010	1	1	04	01	H4036_010_1	10	4	Diag/Rad	01	8a1;8a2;8b1;8b3;		2		2			2		1	30	30
H4036	010	1	1	04	01	H4036_010_1	10	8	$0	10		14c;	1	95.00	1	0.00	0.00	2		2		
H4036	010	1	1	04	01	H4036_010_1	10	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;		2		2			2		1	40	40
H4036	010	1	1	04	01	H4036_010_1	10	6	Specialist	11	7b;7c;7d;7e;7f;7h;7i;	14b;	2		1	60.00	60.00	2		2		
H4036	010	1	1	04	01	H4036_010_1	10	5	PCP	01	7a;7g;		2		1	25.00	25.00	2		2		
H4036	010	2	1	04	01	H4036_010_2	10	1	$0	11	9d;16b;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H4036	010	2	1	04	01	H4036_010_2	10	2	20%	11	8b2;12;	16a;18a;	2		2			2		1	20	20
H4036	010	2	1	04	01	H4036_010_2	10	3	Ambulance	01	10a;		2		1	190.00	190.00	2		1	20	20
H4036	010	2	1	04	01	H4036_010_2	10	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;		2		2			2		1	40	40
H4036	010	2	1	04	01	H4036_010_2	10	6	Specialist	11	7b;7c;7d;7e;7f;7h;7i;	14b;	2		1	60.00	60.00	2		2		
H4036	010	2	1	04	01	H4036_010_2	10	5	PCP	01	7a;7g;		2		1	35.00	35.00	2		2		
H4036	010	2	1	04	01	H4036_010_2	10	4	Diag/Rad	01	8a1;8a2;8b1;8b3;		2		2			2		1	30	30
H4036	010	2	1	04	01	H4036_010_2	10	8	$0	10		14c;	1	95.00	1	0.00	0.00	2		2		
H4036	012	1	1	04	01	H4036_012_1	10	1	$0	11	9d;16b;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H4036	012	1	1	04	01	H4036_012_1	10	8	$0	10		14c;	1	95.00	1	0.00	0.00	2		2		
H4036	012	1	1	04	01	H4036_012_1	10	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;		2		2			2		1	40	40
H4036	012	1	1	04	01	H4036_012_1	10	6	Specialist	11	7b;7c;7d;7e;7f;7h;7i;	14b;	2		1	50.00	50.00	2		2		
H4036	012	1	1	04	01	H4036_012_1	10	5	PCP	01	7a;7g;		2		1	25.00	25.00	2		2		
H4036	012	1	1	04	01	H4036_012_1	10	4	Diag/Rad	01	8a1;8a2;8b1;8b3;		2		2			2		1	30	30
H4036	012	1	1	04	01	H4036_012_1	10	3	Ambulance	01	10a;		2		1	150.00	150.00	2		1	20	20
H4036	012	1	1	04	01	H4036_012_1	10	2	20%	11	8b2;12;	16a;18a;	2		2			2		1	20	20
H4036	012	2	1	04	01	H4036_012_2	10	1	$0	11	9d;16b;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H4036	012	2	1	04	01	H4036_012_2	10	2	20%	11	8b2;12;	16a;18a;	2		2			2		1	20	20
H4036	012	2	1	04	01	H4036_012_2	10	3	Ambulance	01	10a;		2		1	150.00	150.00	2		1	20	20
H4036	012	2	1	04	01	H4036_012_2	10	4	Diag/Rad	01	8a1;8a2;8b1;8b3;		2		2			2		1	30	30
H4036	012	2	1	04	01	H4036_012_2	10	5	PCP	01	7a;7g;		2		1	25.00	25.00	2		2		
H4036	012	2	1	04	01	H4036_012_2	10	6	Specialist	11	7b;7c;7d;7e;7f;7h;7i;	14b;	2		1	50.00	50.00	2		2		
H4036	012	2	1	04	01	H4036_012_2	10	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;		2		2			2		1	40	40
H4036	012	2	1	04	01	H4036_012_2	10	8	$0	10		14c;	1	95.00	1	0.00	0.00	2		2		
H4036	801	0	1	04	01	H4036_801_0	4	1		01	6;14a;		2		2			2		1	0	0
H4036	801	0	1	04	01	H4036_801_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H4036	802	0	1	04	01	H4036_802_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H4036	802	0	1	04	01	H4036_802_0	4	1		01	6;14a;		2		2			2		1	0	0
H4036	803	0	1	04	01	H4036_803_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H4036	803	0	1	04	01	H4036_803_0	4	1		01	6;14a;		2		2			2		1	0	0
H4036	805	0	1	04	01	H4036_805_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H4036	805	0	1	04	01	H4036_805_0	4	1		01	6;14a;		2		2			2		1	0	0
H4036	806	0	2	04	01	H4036_806_0	4	1		01	6;14a;		2		2			2		1	0	0
H4036	806	0	2	04	01	H4036_806_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H4213	016	1	1	09	04	H4213_016_1	8	8	Specialist / Podiatry	01	7d;7f;				1	50.00	50.00	2		1	40	40
H4213	016	1	1	09	04	H4213_016_1	8	9		01	16b;17a;17b;18a;				1	50.00	50.00	2		1	40	40
H4213	016	1	1	09	04	H4213_016_1	8	6	Other Services	01	8a1;8b2;8b3;11a;11b;11c;12;15;				2			2		1	20	40
H4213	016	1	1	09	04	H4213_016_1	8	5	Chiropractic Services	01	7b;				1	20.00	20.00	2		1	40	40
H4213	016	1	1	09	04	H4213_016_1	8	4	Primary Care Physician	01	7a;				1	20.00	20.00	2		1	40	40
H4213	016	1	1	09	04	H4213_016_1	8	3	Preventive / Home Health / Lab Services	11	6;8a2;14a;14d;14e;	14b;	2		2			2		1	0	40
H4213	016	1	1	09	04	H4213_016_1	8	2	Fitness Benefit/Blood Services	11	9d;	9d;14c;	2		2			2		2		
H4213	016	1	1	09	04	H4213_016_1	8	15	Cardiac / Pulmonary Services	01	3-1;3-2;3-3;				1	45.00	45.00	2		1	40	40
H4213	016	1	1	09	04	H4213_016_1	8	14	Ambulatory Surgical Services	01	9b;				1	75.00	75.00	2		1	40	40
H4213	016	1	1	09	04	H4213_016_1	8	13	Outpatient Hospital Services	01	9a;				1	75.00	315.00	2		1	40	40
H4213	016	1	1	09	04	H4213_016_1	8	12	Other Health Care Professional	01	7g;				1	20.00	50.00	2		1	40	40
H4213	016	1	1	09	04	H4213_016_1	8	11	Partial Hospitalization	01	5;				1	55.00	55.00	2		1	40	40
H4213	016	1	1	09	04	H4213_016_1	8	10	Mental Health / Psych /  PT / SP / OT	01	7c;7e;7h;7i;9c;				1	25.00	40.00	2		1	40	40
H4213	016	1	1	09	04	H4213_016_1	8	1	Ambulance Services	01	10a;				1	350.00	350.00	2		2		
H4213	016	1	1	09	04	H4213_016_1	8	7	Diagnostic Radiological Services	01	8b1;				1	315.00	315.00	2		1	40	40
H4213	016	2	1	09	04	H4213_016_2	8	8	Specialist / Podiatry	01	7d;7f;				1	50.00	50.00	2		1	40	40
H4213	016	2	1	09	04	H4213_016_2	8	7	Diagnostic Radiological Services	01	8b1;				1	315.00	315.00	2		1	40	40
H4213	016	2	1	09	04	H4213_016_2	8	6	Other Services	01	8a1;8b2;8b3;11a;11b;11c;12;15;				2			2		1	20	40
H4213	016	2	1	09	04	H4213_016_2	8	5	Chiropractic Services	01	7b;				1	20.00	20.00	2		1	40	40
H4213	016	2	1	09	04	H4213_016_2	8	4	Primary Care Physician	01	7a;				1	20.00	20.00	2		1	40	40
H4213	016	2	1	09	04	H4213_016_2	8	3	Preventive / Home Health / Lab Services	11	6;8a2;14a;14d;14e;	14b;	2		2			2		1	0	40
H4213	016	2	1	09	04	H4213_016_2	8	2	Fitness Benefit/Blood Services	11	9d;	9d;14c;	2		2			2		2		
H4213	016	2	1	09	04	H4213_016_2	8	15	Cardiac / Pulmonary Services	01	3-1;3-2;3-3;				1	45.00	45.00	2		1	40	40
H4213	016	2	1	09	04	H4213_016_2	8	14	Ambulatory Surgical Services	01	9b;				1	75.00	75.00	2		1	40	40
H4213	016	2	1	09	04	H4213_016_2	8	13	Outpatient Hospital Services	01	9a;				1	75.00	315.00	2		1	40	40
H4213	016	2	1	09	04	H4213_016_2	8	12	Other Health Care Professional	01	7g;				1	20.00	50.00	2		1	40	40
H4213	016	2	1	09	04	H4213_016_2	8	11	Partial Hospitalization	01	5;				1	55.00	55.00	2		1	40	40
H4213	016	2	1	09	04	H4213_016_2	8	10	Mental Health / Psych /  PT / SP / OT	01	7c;7e;7h;7i;9c;				1	25.00	40.00	2		1	40	40
H4213	016	2	1	09	04	H4213_016_2	8	1	Ambulance Services	01	10a;				1	350.00	350.00	2		2		
H4213	016	2	1	09	04	H4213_016_2	8	9		01	16b;17a;17b;18a;				1	50.00	50.00	2		1	40	40
H4213	016	3	1	09	04	H4213_016_3	8	1	Ambulance Services	01	10a;				1	350.00	350.00	2		2		
H4213	016	3	1	09	04	H4213_016_3	8	10	Mental Health / Psych /  PT / SP / OT	01	7c;7e;7h;7i;9c;				1	25.00	40.00	2		1	40	40
H4213	016	3	1	09	04	H4213_016_3	8	9		01	16b;17a;17b;18a;				1	50.00	50.00	2		1	40	40
H4213	016	3	1	09	04	H4213_016_3	8	8	Specialist / Podiatry	01	7d;7f;				1	50.00	50.00	2		1	40	40
H4213	016	3	1	09	04	H4213_016_3	8	7	Diagnostic Radiological Services	01	8b1;				1	315.00	315.00	2		1	40	40
H4213	016	3	1	09	04	H4213_016_3	8	6	Other Services	01	8a1;8b2;8b3;11a;11b;11c;12;15;				2			2		1	20	40
H4213	016	3	1	09	04	H4213_016_3	8	5	Chiropractic Services	01	7b;				1	20.00	20.00	2		1	40	40
H4213	016	3	1	09	04	H4213_016_3	8	4	Primary Care Physician	01	7a;				1	25.00	25.00	2		1	40	40
H4213	016	3	1	09	04	H4213_016_3	8	3	Preventive / Home Health / Lab Services	11	6;8a2;14a;14d;14e;	14b;	2		2			2		1	0	40
H4213	016	3	1	09	04	H4213_016_3	8	2	Fitness Benefit/Blood Services	11	9d;	9d;14c;	2		2			2		2		
H4213	016	3	1	09	04	H4213_016_3	8	15	Cardiac / Pulmonary Services	01	3-1;3-2;3-3;				1	45.00	45.00	2		1	40	40
H4213	016	3	1	09	04	H4213_016_3	8	14	Ambulatory Surgical Services	01	9b;				1	75.00	75.00	2		1	40	40
H4213	016	3	1	09	04	H4213_016_3	8	13	Outpatient Hospital Services	01	9a;				1	75.00	315.00	2		1	40	40
H4213	016	3	1	09	04	H4213_016_3	8	12	Other Health Care Professional	01	7g;				1	25.00	50.00	2		1	40	40
H4213	016	3	1	09	04	H4213_016_3	8	11	Partial Hospitalization	01	5;				1	55.00	55.00	2		1	40	40
H4213	016	4	1	09	04	H4213_016_4	8	1	Ambulance Services	01	10a;				1	350.00	350.00	2		2		
H4213	016	4	1	09	04	H4213_016_4	8	9		01	16b;17a;17b;18a;				1	50.00	50.00	2		1	40	40
H4213	016	4	1	09	04	H4213_016_4	8	7	Diagnostic Radiological Services	01	8b1;				1	315.00	315.00	2		1	40	40
H4213	016	4	1	09	04	H4213_016_4	8	6	Other Services	01	8a1;8b2;8b3;11a;11b;11c;12;15;				2			2		1	20	40
H4213	016	4	1	09	04	H4213_016_4	8	5	Chiropractic Services	01	7b;				1	20.00	20.00	2		1	40	40
H4213	016	4	1	09	04	H4213_016_4	8	4	Primary Care Physician	01	7a;				1	25.00	25.00	2		1	40	40
H4213	016	4	1	09	04	H4213_016_4	8	3	Preventive / Home Health / Lab Services	11	6;8a2;14a;14d;14e;	14b;	2		2			2		1	0	40
H4213	016	4	1	09	04	H4213_016_4	8	2	Fitness Benefit/Blood Services	11	9d;	9d;14c;	2		2			2		2		
H4213	016	4	1	09	04	H4213_016_4	8	15	Cardiac / Pulmonary Services	01	3-1;3-2;3-3;				1	45.00	45.00	2		1	40	40
H4213	016	4	1	09	04	H4213_016_4	8	14	Ambulatory Surgical Services	01	9b;				1	75.00	75.00	2		1	40	40
H4213	016	4	1	09	04	H4213_016_4	8	13	Outpatient Hospital Services	01	9a;				1	75.00	315.00	2		1	40	40
H4213	016	4	1	09	04	H4213_016_4	8	12	Other Health Care Professional	01	7g;				1	25.00	50.00	2		1	40	40
H4213	016	4	1	09	04	H4213_016_4	8	11	Partial Hospitalization	01	5;				1	55.00	55.00	2		1	40	40
H4213	016	4	1	09	04	H4213_016_4	8	10	Mental Health / Psych /  PT / SP / OT	01	7c;7e;7h;7i;9c;				1	25.00	40.00	2		1	40	40
H4213	016	4	1	09	04	H4213_016_4	8	8	Specialist / Podiatry	01	7d;7f;				1	50.00	50.00	2		1	40	40
H4213	017	1	1	09	04	H4213_017_1	7	13	Outpatient Hospital Services	01	9a;				1	75.00	315.00	2		1	40	40
H4213	017	1	1	09	04	H4213_017_1	7	14	Ambulatory Surgical Services	01	9b;				1	75.00	75.00	2		1	40	40
H4213	017	1	1	09	04	H4213_017_1	7	15	Cardiac / Pulmonary Services	01	3-1;3-2;3-3;				1	45.00	45.00	2		1	40	40
H4213	017	1	1	09	04	H4213_017_1	7	2	Fitness Benefit/Blood Services	11	9d;	9d;14c;	2		2			2		2		
H4213	017	1	1	09	04	H4213_017_1	7	3	Preventive / Home Health / Lab Services	11	6;8a2;14a;14d;14e;	14b;	2		2			2		1	0	40
H4213	017	1	1	09	04	H4213_017_1	7	4	Primary Care Physician	01	7a;				1	20.00	20.00	2		1	40	40
H4213	017	1	1	09	04	H4213_017_1	7	5	Chiropractic Services	01	7b;				1	20.00	20.00	2		1	40	40
H4213	017	1	1	09	04	H4213_017_1	7	6	Other Services	01	8a1;8b2;8b3;11a;11b;11c;12;15;				2			2		1	20	40
H4213	017	1	1	09	04	H4213_017_1	7	7	Diagnostic Radiological Services	01	8b1;				1	315.00	315.00	2		1	40	40
H4213	017	1	1	09	04	H4213_017_1	7	8	Specialist / Podiatry	01	7d;7f;				1	50.00	50.00	2		1	40	40
H4213	017	1	1	09	04	H4213_017_1	7	9		01	16b;17a;17b;18a;				1	50.00	50.00	2		1	40	40
H4213	017	1	1	09	04	H4213_017_1	7	1	Ambulance Services	01	10a;				1	350.00	350.00	2		2		
H4213	017	1	1	09	04	H4213_017_1	7	10	Mental Health / Psych /  PT / SP / OT	01	7c;7e;7h;7i;9c;				1	25.00	40.00	2		1	40	40
H4213	017	1	1	09	04	H4213_017_1	7	11	Partial Hospitalization	01	5;				1	55.00	55.00	2		1	40	40
H4213	017	1	1	09	04	H4213_017_1	7	12	Other Health Care Professional	01	7g;				1	20.00	50.00	2		1	40	40
H4213	017	2	1	09	04	H4213_017_2	8	15	Cardiac / Pulmonary Services	01	3-1;3-2;3-3;				1	45.00	45.00	2		1	40	40
H4213	017	2	1	09	04	H4213_017_2	8	9		01	16b;17a;17b;18a;				1	50.00	50.00	2		1	40	40
H4213	017	2	1	09	04	H4213_017_2	8	13	Outpatient Hospital Services	01	9a;				1	75.00	315.00	2		1	40	40
H4213	017	2	1	09	04	H4213_017_2	8	12	Other Health Care Professional	01	7g;				1	20.00	50.00	2		1	40	40
H4213	017	2	1	09	04	H4213_017_2	8	11	Partial Hospitalization	01	5;				1	55.00	55.00	2		1	40	40
H4213	017	2	1	09	04	H4213_017_2	8	10	Mental Health / Psych /  PT / SP / OT	01	7c;7e;7h;7i;9c;				1	25.00	40.00	2		1	40	40
H4213	017	2	1	09	04	H4213_017_2	8	1	Ambulance Services	01	10a;				1	350.00	350.00	2		2		
H4213	017	2	1	09	04	H4213_017_2	8	2	Fitness Benefit/Blood Services	11	9d;	9d;14c;	2		2			2		2		
H4213	017	2	1	09	04	H4213_017_2	8	3	Preventive / Home Health / Lab Services	11	6;8a2;14a;14d;14e;	14b;	2		2			2		1	0	40
H4213	017	2	1	09	04	H4213_017_2	8	4	Primary Care Physician	01	7a;				1	20.00	20.00	2		1	40	40
H4213	017	2	1	09	04	H4213_017_2	8	5	Chiropractic Services	01	7b;				1	20.00	20.00	2		1	40	40
H4213	017	2	1	09	04	H4213_017_2	8	6	Other Services	01	8a1;8b2;8b3;11a;11b;11c;12;15;				2			2		1	20	40
H4213	017	2	1	09	04	H4213_017_2	8	7	Diagnostic Radiological Services	01	8b1;				1	315.00	315.00	2		1	40	40
H4213	017	2	1	09	04	H4213_017_2	8	8	Specialist / Podiatry	01	7d;7f;				1	50.00	50.00	2		1	40	40
H4213	017	2	1	09	04	H4213_017_2	8	14	Ambulatory Surgical Services	01	9b;				1	75.00	75.00	2		1	40	40
H4213	017	5	1	09	04	H4213_017_5	7	15	Cardiac / Pulmonary Services	01	3-1;3-2;3-3;				1	45.00	45.00	2		1	40	40
H4213	017	5	1	09	04	H4213_017_5	7	14	Ambulatory Surgical Services	01	9b;				1	75.00	75.00	2		1	40	40
H4213	017	5	1	09	04	H4213_017_5	7	13	Outpatient Hospital Services	01	9a;				1	75.00	315.00	2		1	40	40
H4213	017	5	1	09	04	H4213_017_5	7	12	Other Health Care Professional	01	7g;				1	25.00	50.00	2		1	40	40
H4213	017	5	1	09	04	H4213_017_5	7	11	Partial Hospitalization	01	5;				1	55.00	55.00	2		1	40	40
H4213	017	5	1	09	04	H4213_017_5	7	10	Mental Health / Psych /  PT / SP / OT	01	7c;7e;7h;7i;9c;				1	25.00	40.00	2		1	40	40
H4213	017	5	1	09	04	H4213_017_5	7	1	Ambulance Services	01	10a;				1	350.00	350.00	2		2		
H4213	017	5	1	09	04	H4213_017_5	7	2	Fitness Benefit/Blood Services	11	9d;	9d;14c;	2		2			2		2		
H4213	017	5	1	09	04	H4213_017_5	7	9		01	16b;17a;17b;18a;				1	50.00	50.00	2		1	40	40
H4213	017	5	1	09	04	H4213_017_5	7	8	Specialist / Podiatry	01	7d;7f;				1	50.00	50.00	2		1	40	40
H4213	017	5	1	09	04	H4213_017_5	7	7	Diagnostic Radiological Services	01	8b1;				1	315.00	315.00	2		1	40	40
H4213	017	5	1	09	04	H4213_017_5	7	6	Other Services	01	8a1;8b2;8b3;11a;11b;11c;12;15;				2			2		1	20	40
H4213	017	5	1	09	04	H4213_017_5	7	5	Chiropractic Services	01	7b;				1	20.00	20.00	2		1	40	40
H4213	017	5	1	09	04	H4213_017_5	7	4	Primary Care Physician	01	7a;				1	25.00	25.00	2		1	40	40
H4213	017	5	1	09	04	H4213_017_5	7	3	Preventive / Home Health / Lab Services	11	6;8a2;14a;14d;14e;	14b;	2		2			2		1	0	40
H4213	017	6	1	09	04	H4213_017_6	8	1	Ambulance Services	01	10a;				1	350.00	350.00	2		2		
H4213	017	6	1	09	04	H4213_017_6	8	9		01	16b;17a;17b;18a;				1	50.00	50.00	2		1	40	40
H4213	017	6	1	09	04	H4213_017_6	8	11	Partial Hospitalization	01	5;				1	55.00	55.00	2		1	40	40
H4213	017	6	1	09	04	H4213_017_6	8	12	Other Health Care Professional	01	7g;				1	25.00	50.00	2		1	40	40
H4213	017	6	1	09	04	H4213_017_6	8	13	Outpatient Hospital Services	01	9a;				1	75.00	315.00	2		1	40	40
H4213	017	6	1	09	04	H4213_017_6	8	14	Ambulatory Surgical Services	01	9b;				1	75.00	75.00	2		1	40	40
H4213	017	6	1	09	04	H4213_017_6	8	15	Cardiac / Pulmonary Services	01	3-1;3-2;3-3;				1	45.00	45.00	2		1	40	40
H4213	017	6	1	09	04	H4213_017_6	8	8	Specialist / Podiatry	01	7d;7f;				1	50.00	50.00	2		1	40	40
H4213	017	6	1	09	04	H4213_017_6	8	7	Diagnostic Radiological Services	01	8b1;				1	315.00	315.00	2		1	40	40
H4213	017	6	1	09	04	H4213_017_6	8	6	Other Services	01	8a1;8b2;8b3;11a;11b;11c;12;15;				2			2		1	20	40
H4213	017	6	1	09	04	H4213_017_6	8	5	Chiropractic Services	01	7b;				1	20.00	20.00	2		1	40	40
H4213	017	6	1	09	04	H4213_017_6	8	4	Primary Care Physician	01	7a;				1	25.00	25.00	2		1	40	40
H4213	017	6	1	09	04	H4213_017_6	8	3	Preventive / Home Health / Lab Services	11	6;8a2;14a;14d;14e;	14b;	2		2			2		1	0	40
H4213	017	6	1	09	04	H4213_017_6	8	2	Fitness Benefit/Blood Services	11	9d;	9d;14c;	2		2			2		2		
H4213	017	6	1	09	04	H4213_017_6	8	10	Mental Health / Psych /  PT / SP / OT	01	7c;7e;7h;7i;9c;				1	25.00	40.00	2		1	40	40
H4497	001	1	1	04	01	H4497_001_1	10	1	OON Benefits	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;12;14a;14d;14e;16b;17a;17b;18a;	9d;	2		2			2		1	30	30
H4497	001	1	1	04	01	H4497_001_1	10	3	OTC Benefit	10		13b;	1	20.00	2			2		2		
H4497	001	1	1	04	01	H4497_001_1	10	4	Meal Benefit	10		13c;	2		2			2		2		
H4497	001	1	1	04	01	H4497_001_1	10	5	Other Supplemental Coverage	10		14c;	1	150.00	2			2		2		
H4497	001	1	1	04	01	H4497_001_1	10	2	Dental Supplemental Coverage	10		16a;	2		2			2		1	50	50
H4497	001	1	1	04	01	H4497_001_1	10	7	Medicare Part B Rx Drugs	01	15;		2		2			2		1	20	20
H4497	001	1	1	04	01	H4497_001_1	10	8	Routine Eye Exams	10		17a;	2		1	50.00	50.00	2		2		
H4497	001	1	1	04	01	H4497_001_1	10	9	Routine Eyewear	10		17b;	2		2			2		2		
H4497	001	1	1	04	01	H4497_001_1	10	6	Diabetic Supplies and Services	01	11c;		2		2			2		2		
H4497	001	2	1	04	01	H4497_001_2	8	6	Diabetic Supplies and Services	01	11c;		2		2			2		2		
H4497	001	2	1	04	01	H4497_001_2	8	1	OON Benefits	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;12;14a;14d;14e;16b;17a;17b;18a;	9d;	2		2			2		1	30	30
H4497	001	2	1	04	01	H4497_001_2	8	2	Dental Supplemental Coverage	10		16a;	2		2			2		1	50	50
H4497	001	2	1	04	01	H4497_001_2	8	3	OTC Benefit	10		13b;	1	20.00	2			2		2		
H4497	001	2	1	04	01	H4497_001_2	8	4	Meal Benefit	10		13c;	2		2			2		2		
H4497	001	2	1	04	01	H4497_001_2	8	5	Other Supplemental Coverage	10		14c;	1	150.00	2			2		2		
H4497	001	2	1	04	01	H4497_001_2	8	7	Medicare Part B Rx Drugs	01	15;		2		2			2		1	20	20
H4497	001	2	1	04	01	H4497_001_2	8	8	Routine Eye Exams	10		17a;	2		1	50.00	50.00	2		2		
H4497	001	2	1	04	01	H4497_001_2	8	9	Routine Eyewear	10		17b;	2		2			2		2		
H4497	002	1	1	04	01	H4497_002_1	11	8	Routine Eye Exams	10		17a;	2		1	50.00	50.00	2		2		
H4497	002	1	1	04	01	H4497_002_1	11	7	Medicare Part B Rx Drugs	01	15;		2		2			2		1	20	20
H4497	002	1	1	04	01	H4497_002_1	11	6	Diabetic Supplies and Services	01	11c;		2		2			2		2		
H4497	002	1	1	04	01	H4497_002_1	11	5	Other Supplemental Coverage	10		14c;	1	150.00	2			2		2		
H4497	002	1	1	04	01	H4497_002_1	11	1	OON Benefits	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;12;14a;14d;14e;16b;17a;17b;18a;	9d;	2		2			2		1	30	30
H4497	002	1	1	04	01	H4497_002_1	11	4	Meal Benefit	10		13c;	2		2			2		2		
H4497	002	1	1	04	01	H4497_002_1	11	3	OTC Benefit	10		13b;	1	20.00	2			2		2		
H4497	002	1	1	04	01	H4497_002_1	11	9	Routine Eyewear	10		17b;	2		2			2		2		
H4497	002	1	1	04	01	H4497_002_1	11	2	Dental Supplemental Coverage	10		16a;	2		2			2		1	50	50
H4497	002	2	1	04	01	H4497_002_2	11	9	Routine Eyewear	10		17b;	2		2			2		2		
H4497	002	2	1	04	01	H4497_002_2	11	7	Medicare Part B Rx Drugs	01	15;		2		2			2		1	20	20
H4497	002	2	1	04	01	H4497_002_2	11	8	Routine Eye Exams	10		17a;	2		1	50.00	50.00	2		2		
H4497	002	2	1	04	01	H4497_002_2	11	6	Diabetic Supplies and Services	01	11c;		2		2			2		2		
H4497	002	2	1	04	01	H4497_002_2	11	5	Other Supplemental Coverage	10		14c;	1	150.00	2			2		2		
H4497	002	2	1	04	01	H4497_002_2	11	4	Meal Benefit	10		13c;	2		2			2		2		
H4497	002	2	1	04	01	H4497_002_2	11	3	OTC Benefit	10		13b;	1	20.00	2			2		2		
H4497	002	2	1	04	01	H4497_002_2	11	2	Dental Supplemental Coverage	10		16a;	2		2			2		1	50	50
H4497	002	2	1	04	01	H4497_002_2	11	1	OON Benefits	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;12;14a;14d;14e;16b;17a;17b;18a;	9d;	2		2			2		1	30	30
H4497	003	1	1	04	01	H4497_003_1	9	10	Eyewear	10		17b;	2		2			2		2		
H4497	003	1	1	04	01	H4497_003_1	9	2	Preventive Dental	10		16a;	2		2			2		1	50	50
H4497	003	1	1	04	01	H4497_003_1	9	3	OTC Benefit	10		13b;	1	20.00	2			2		2		
H4497	003	1	1	04	01	H4497_003_1	9	4	Meal Benefit	10		13c;	2		2			2		2		
H4497	003	1	1	04	01	H4497_003_1	9	8	Comprehensive Dental	10		16b;	2		2			2		1	55	70
H4497	003	1	1	04	01	H4497_003_1	9	6	Diabetic Supplies and Services	01	11c;		2		2			2		2		
H4497	003	1	1	04	01	H4497_003_1	9	7	Medicare Part B Rx Drugs	01	15;		2		2			2		1	20	20
H4497	003	1	1	04	01	H4497_003_1	9	1	OON Benefits	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;12;14a;14d;14e;16b;17a;17b;18a;	9d;	2		2			2		1	30	30
H4497	003	1	1	04	01	H4497_003_1	9	9	Routine Eye Exams	10		17a;	2		1	50.00	50.00	2		2		
H4497	003	1	1	04	01	H4497_003_1	9	5	Other Supplemental Coverage	10		14c;	1	150.00	2			2		2		
H4497	003	2	1	04	01	H4497_003_2	9	1	OON Benefits	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;12;14a;14d;14e;16b;17a;17b;18a;	9d;	2		2			2		1	30	30
H4497	003	2	1	04	01	H4497_003_2	9	10	Eyewear	10		17b;	2		2			2		2		
H4497	003	2	1	04	01	H4497_003_2	9	2	Preventive Dental	10		16a;	2		2			2		1	50	50
H4497	003	2	1	04	01	H4497_003_2	9	3	OTC Benefit	10		13b;	1	20.00	2			2		2		
H4497	003	2	1	04	01	H4497_003_2	9	4	Meal Benefit	10		13c;	2		2			2		2		
H4497	003	2	1	04	01	H4497_003_2	9	5	Other Supplemental Coverage	10		14c;	1	150.00	2			2		2		
H4497	003	2	1	04	01	H4497_003_2	9	7	Medicare Part B Rx Drugs	01	15;		2		2			2		1	20	20
H4497	003	2	1	04	01	H4497_003_2	9	6	Diabetic Supplies and Services	01	11c;		2		2			2		2		
H4497	003	2	1	04	01	H4497_003_2	9	9	Routine Eye Exams	10		17a;	2		1	50.00	50.00	2		2		
H4497	003	2	1	04	01	H4497_003_2	9	8	Comprehensive Dental	10		16b;	2		2			2		1	55	70
H4497	801	0	1	04	01	H4497_801_0	1	1		01	6;14a;		2		2			2		1	0	0
H4497	801	0	1	04	01	H4497_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H4497	802	0	1	04	01	H4497_802_0	1	1		01	6;14a;		2		2			2		1	0	0
H4497	802	0	1	04	01	H4497_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H4497	803	0	1	04	01	H4497_803_0	1	1		01	6;14a;		2		2			2		1	0	0
H4497	803	0	1	04	01	H4497_803_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H4605	001	0	1	04	01	H4605_001_0	5	1	$0 copay	10		14c;17b;	2		2			2		2		
H4605	001	0	1	04	01	H4605_001_0	5	2	$40 copay	10		17a;	2		1	40.00	40.00	2		2		
H4605	001	0	1	04	01	H4605_001_0	5	3	$300 copay	01	10a;		2		1	300.00	300.00	2		2		
H4605	001	0	1	04	01	H4605_001_0	5	4	30% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;	2		2			2		1	30	30
H4605	001	0	1	04	01	H4605_001_0	5	5	50% coinsurance	10		16a;	2		2			2		1	50	50
H4605	002	0	1	04	01	H4605_002_0	7	2	$40 copay	10		17a;	2		1	40.00	40.00	2		2		
H4605	002	0	1	04	01	H4605_002_0	7	1	$0 copay	10		14c;17b;	2		2			2		2		
H4605	002	0	1	04	01	H4605_002_0	7	3	$300 copay	01	10a;		2		1	300.00	300.00	2		2		
H4605	002	0	1	04	01	H4605_002_0	7	4	30% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;	2		2			2		1	30	30
H4605	002	0	1	04	01	H4605_002_0	7	5	50% coinsurance	10		16a;	2		2			2		1	50	50
H4605	004	0	1	04	01	H4605_004_0	7	2	$30 copay	10		17a;	2		1	30.00	30.00	2		2		
H4605	004	0	1	04	01	H4605_004_0	7	1	$0 copay	10		14c;17b;	2		2			2		2		
H4605	004	0	1	04	01	H4605_004_0	7	3	$250 copay	01	10a;		2		1	250.00	250.00	2		2		
H4605	004	0	1	04	01	H4605_004_0	7	6	$599 or $899 copay	10		18b;	2		1	599.00	899.00	2		2		
H4605	004	0	1	04	01	H4605_004_0	7	5	50% coinsurance	10		16a;	2		2			2		1	50	50
H4605	004	0	1	04	01	H4605_004_0	7	4	30% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;	2		2			2		1	30	30
H4605	801	0	1	04	01	H4605_801_0	7	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H4605	801	0	1	04	01	H4605_801_0	7	1		01	6;14a;		2		2			2		1	0	0
H4605	802	0	1	04	01	H4605_802_0	6	1		01	6;14a;		2		2			2		1	0	0
H4605	802	0	1	04	01	H4605_802_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H4738	002	0	1	04	01	H4738_002_0	3	1	20	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;12;14a;14d;14e;15;	9d;	2		2			2		1	20	20
H4738	002	0	1	04	01	H4738_002_0	3	2	23	01	11a;11b;11c;		2		2			2		1	23	23
H4738	002	0	1	04	01	H4738_002_0	3	3	50	11	16b;17a;17b;18a;	14c;17a;17b;18a;18b;	2		2			2		1	50	50
H4754	004	0	1	04	01	H4754_004_0	11	11	Diagnostic Testing	01	8a1;		2		1	15.00	15.00	2		2		
H4754	004	0	1	04	01	H4754_004_0	11	10	Eye wear - Routine	10		17b;	2		2			2		2		
H4754	004	0	1	04	01	H4754_004_0	11	1	30% coinsurance	11	3-1;3-2;3-3;6;7b;7c;7e;7f;7h;7i;9c;9d;11c;12;14a;14d;14e;15;16b;18a;	14b;18a;	2		2			2		1	30	30
H4754	004	0	1	04	01	H4754_004_0	11	3	Specialist Copay	01	5;7d;		2		1	40.00	40.00	2		2		
H4754	004	0	1	04	01	H4754_004_0	11	4	$0 copay	11	17b;	14c;	2		2			2		2		
H4754	004	0	1	04	01	H4754_004_0	11	5	Outpatient Hospital	01	9a;		2		1	350.00	350.00	2		2		
H4754	004	0	1	04	01	H4754_004_0	11	6	ASC	01	9b;		2		1	350.00	350.00	2		2		
H4754	004	0	1	04	01	H4754_004_0	11	7	Office visit copay	11	8b1;8b2;8b3;17a;	17a;	2		2			2		1	30	30
H4754	004	0	1	04	01	H4754_004_0	11	8	Ambulance	01	10a;		2		1	200.00	200.00	2		2		
H4754	004	0	1	04	01	H4754_004_0	11	12	Lab	01	8a2;		2		1	0.00	15.00	2		2		
H4754	004	0	1	04	01	H4754_004_0	11	9	Other health care professional	01	7g;		2		1	20.00	40.00	2		2		
H4754	004	0	1	04	01	H4754_004_0	11	2	PCP Copay	01	7a;		2		1	20.00	20.00	2		2		
H4754	004	0	1	04	01	H4754_004_0	11	13	40% coinsurnace	01	11a;11b;		2		2			2		1	0	40
H4754	006	0	1	04	01	H4754_006_0	9	6	ASC	01	9b;		2		1	350.00	350.00	2		2		
H4754	006	0	1	04	01	H4754_006_0	9	5	Outpatient Hospital	01	9a;		2		1	350.00	350.00	2		2		
H4754	006	0	1	04	01	H4754_006_0	9	4	20% coinsurance	01	6;		2		2			2		1	20	20
H4754	006	0	1	04	01	H4754_006_0	9	3	Specialist Copay	01	5;7d;		2		1	45.00	45.00	2		2		
H4754	006	0	1	04	01	H4754_006_0	9	2	PCP Copay	01	7a;		2		1	20.00	20.00	2		2		
H4754	006	0	1	04	01	H4754_006_0	9	12	40% coinsurance	01	11a;11b;		2		2			2		1	0	40
H4754	006	0	1	04	01	H4754_006_0	9	11	Routine eyewear	10		17b;	2		2			2		2		
H4754	006	0	1	04	01	H4754_006_0	9	10	$0 copay	11	17b;	14c;	2		2			2		2		
H4754	006	0	1	04	01	H4754_006_0	9	1	20% coinsurance	11	3-1;3-2;3-3;7b;7c;7e;7f;7h;7i;9c;9d;11c;12;14a;14d;14e;15;16b;18a;	14b;18a;	2		2			2		1	20	20
H4754	006	0	1	04	01	H4754_006_0	9	7	20% coinsurance	11	8a1;8a2;8b1;8b2;8b3;17a;	17a;	2		2			2		1	20	20
H4754	006	0	1	04	01	H4754_006_0	9	9	Other health care professional	01	7g;		2		1	20.00	45.00	2		2		
H4754	006	0	1	04	01	H4754_006_0	9	8	Ambulance	01	10a;		2		1	150.00	150.00	2		2		
H4754	007	0	1	04	01	H4754_007_0	9	1	30% coinsurance	11	3-1;3-2;3-3;7b;7c;7e;7f;7h;7i;9c;9d;11c;12;14a;14d;14e;15;16b;18a;	14b;18a;	2		2			2		1	30	30
H4754	007	0	1	04	01	H4754_007_0	9	10	Routine eyewear	10		17b;	2		2			2		2		
H4754	007	0	1	04	01	H4754_007_0	9	9	Other health care professional	01	7g;		2		1	25.00	45.00	2		2		
H4754	007	0	1	04	01	H4754_007_0	9	8	Ambulance	01	10a;		2		1	150.00	150.00	2		2		
H4754	007	0	1	04	01	H4754_007_0	9	7	Office visit copay	11	8a1;8a2;8b1;8b2;8b3;17a;	17a;	2		2			2		1	30	30
H4754	007	0	1	04	01	H4754_007_0	9	6	ASC	01	9b;		2		1	350.00	350.00	2		2		
H4754	007	0	1	04	01	H4754_007_0	9	5	$0 copay	11	17b;	14c;	2		2			2		2		
H4754	007	0	1	04	01	H4754_007_0	9	4	30% coinsurance	01	6;		2		2			2		1	30	30
H4754	007	0	1	04	01	H4754_007_0	9	3	Specialist Copay	01	5;7d;		2		1	45.00	45.00	2		2		
H4754	007	0	1	04	01	H4754_007_0	9	2	PCP Copay	01	7a;		2		1	25.00	25.00	2		2		
H4754	007	0	1	04	01	H4754_007_0	9	12	40% coinsurance	01	11a;11b;		2		2			2		1	0	40
H4754	007	0	1	04	01	H4754_007_0	9	11	Outpatient Hospital	01	9a;		2		1	350.00	350.00	2		2		
H4754	008	0	1	04	01	H4754_008_0	8	1	30% coinsurance	11	3-1;3-2;3-3;7b;7c;7e;7f;7h;7i;9c;9d;11c;12;14a;14d;14e;15;16b;18a;	14b;18a;	2		2			2		1	30	30
H4754	008	0	1	04	01	H4754_008_0	8	7	Office visit copay	11	8a1;8a2;8b1;8b2;8b3;17a;	17a;	2		2			2		1	30	30
H4754	008	0	1	04	01	H4754_008_0	8	8	Ambulance	01	10a;		2		1	150.00	150.00	2		2		
H4754	008	0	1	04	01	H4754_008_0	8	6	ASC	01	9b;		2		1	350.00	350.00	2		2		
H4754	008	0	1	04	01	H4754_008_0	8	5	$0 copay	11	17b;	14c;	2		2			2		2		
H4754	008	0	1	04	01	H4754_008_0	8	9	Other health care professional	01	7g;		2		1	25.00	45.00	2		2		
H4754	008	0	1	04	01	H4754_008_0	8	3	Specialist Copay	01	5;7d;		2		1	45.00	45.00	2		2		
H4754	008	0	1	04	01	H4754_008_0	8	2	PCP Copay	01	7a;		2		1	25.00	25.00	2		2		
H4754	008	0	1	04	01	H4754_008_0	8	12	DME	01	11a;11b;		2		2			2		1	0	30
H4754	008	0	1	04	01	H4754_008_0	8	11	Outpatient Hospital	01	9a;		2		1	350.00	350.00	2		2		
H4754	008	0	1	04	01	H4754_008_0	8	10	Routine eyewear	10		17b;	2		2			2		2		
H4754	008	0	1	04	01	H4754_008_0	8	4	30% coinsurance	01	6;		2		2			2		1	30	30
H4754	009	0	1	04	01	H4754_009_0	9	9	Other health care professional	01	7g;		2		1	25.00	45.00	2		2		
H4754	009	0	1	04	01	H4754_009_0	9	1	30% coinsurance	11	3-1;3-2;3-3;6;7b;7c;7e;7f;7h;7i;9c;9d;11c;12;14a;14d;14e;15;16b;18a;	14b;18a;	2		2			2		1	30	30
H4754	009	0	1	04	01	H4754_009_0	9	10	Routine eyewear	10		17b;	2		2			2		2		
H4754	009	0	1	04	01	H4754_009_0	9	11	Outpatient Hospital	01	9a;		2		1	350.00	350.00	2		2		
H4754	009	0	1	04	01	H4754_009_0	9	2	PCP Copay	01	7a;		2		1	25.00	25.00	2		2		
H4754	009	0	1	04	01	H4754_009_0	9	3	Specialist Copay	01	5;7d;		2		1	45.00	45.00	2		2		
H4754	009	0	1	04	01	H4754_009_0	9	4	20-30% coinsurance	01	11a;11b;		2		2			2		1	0	30
H4754	009	0	1	04	01	H4754_009_0	9	5	$0 copay	11	17b;	14c;	2		2			2		2		
H4754	009	0	1	04	01	H4754_009_0	9	6	ASC	01	9b;		2		1	350.00	350.00	2		2		
H4754	009	0	1	04	01	H4754_009_0	9	7	Office visit copay	11	8a1;8a2;8b1;8b2;8b3;17a;	17a;	2		2			2		1	30	30
H4754	009	0	1	04	01	H4754_009_0	9	8	Ambulance	01	10a;		2		1	155.00	155.00	2		2		
H4754	010	0	1	04	01	H4754_010_0	8	5	$0 copay	11	17b;	14c;	2		2			2		2		
H4754	010	0	1	04	01	H4754_010_0	8	4	20-30% coinsurance	01	11a;11b;		2		2			2		1	0	30
H4754	010	0	1	04	01	H4754_010_0	8	3	Specialist Copay	01	5;7d;		2		1	45.00	45.00	2		2		
H4754	010	0	1	04	01	H4754_010_0	8	2	PCP Copay	01	7a;		2		1	25.00	25.00	2		2		
H4754	010	0	1	04	01	H4754_010_0	8	11	Outpatient Hospital	01	9a;		2		1	350.00	350.00	2		2		
H4754	010	0	1	04	01	H4754_010_0	8	9	Other health care professional	01	7g;		2		1	25.00	45.00	2		2		
H4754	010	0	1	04	01	H4754_010_0	8	1	30% coinsurance	11	3-1;3-2;3-3;6;7b;7c;7e;7f;7h;7i;9c;9d;11c;12;14a;14d;14e;15;16b;18a;	14b;18a;	2		2			2		1	30	30
H4754	010	0	1	04	01	H4754_010_0	8	6	ASC	01	9b;		2		1	350.00	350.00	2		2		
H4754	010	0	1	04	01	H4754_010_0	8	7	Office visit copay	11	8a1;8a2;8b1;8b2;8b3;17a;	17a;	2		2			2		1	30	30
H4754	010	0	1	04	01	H4754_010_0	8	8	Ambulance	01	10a;		2		1	155.00	155.00	2		2		
H4754	010	0	1	04	01	H4754_010_0	8	10	Routine eyewear	10		17b;	2		2			2		2		
H4754	011	0	1	04	01	H4754_011_0	8	5	$0 copay	11	17b;	14c;	2		2			2		2		
H4754	011	0	1	04	01	H4754_011_0	8	4	30% coinsurance	01	11a;11b;		2		2			2		1	0	30
H4754	011	0	1	04	01	H4754_011_0	8	3	Specialist Copay	01	5;7d;		2		1	45.00	45.00	2		2		
H4754	011	0	1	04	01	H4754_011_0	8	2	PCP Copay	01	7a;		2		1	25.00	25.00	2		2		
H4754	011	0	1	04	01	H4754_011_0	8	11	Outpatient Hospital	01	9a;		2		1	350.00	350.00	2		2		
H4754	011	0	1	04	01	H4754_011_0	8	10	Routine eyewear	10		17b;	2		2			2		2		
H4754	011	0	1	04	01	H4754_011_0	8	1	30% coinsurance	11	3-1;3-2;3-3;6;7b;7c;7e;7f;7h;7i;9c;9d;11c;12;14a;14d;14e;15;16b;18a;	14b;18a;	2		2			2		1	30	30
H4754	011	0	1	04	01	H4754_011_0	8	6	ASC	01	9b;		2		1	350.00	350.00	2		2		
H4754	011	0	1	04	01	H4754_011_0	8	9	Other health care professional	01	7g;		2		1	25.00	45.00	2		2		
H4754	011	0	1	04	01	H4754_011_0	8	8	Ambulance	01	10a;		2		1	155.00	155.00	2		2		
H4754	011	0	1	04	01	H4754_011_0	8	7	Office visit copay	11	8a1;8a2;8b1;8b2;8b3;17a;	17a;	2		2			2		1	30	30
H4754	012	0	1	04	01	H4754_012_0	8	1	30% coinsurance	11	3-1;3-2;3-3;6;7b;7c;7e;7f;7h;7i;9c;9d;11c;12;14a;14d;14e;15;16b;18a;	14b;18a;	2		2			2		1	30	30
H4754	012	0	1	04	01	H4754_012_0	8	10	Routine eyewear	10		17b;	2		2			2		2		
H4754	012	0	1	04	01	H4754_012_0	8	9	Other health care professional	01	7g;		2		1	25.00	45.00	2		2		
H4754	012	0	1	04	01	H4754_012_0	8	8	Ambulance	01	10a;		2		1	155.00	155.00	2		2		
H4754	012	0	1	04	01	H4754_012_0	8	7	Office visit copay	11	8a1;8a2;8b1;8b2;8b3;17a;	17a;	2		2			2		1	30	30
H4754	012	0	1	04	01	H4754_012_0	8	11	Outpatient Hospital	01	9a;		2		1	350.00	350.00	2		2		
H4754	012	0	1	04	01	H4754_012_0	8	2	PCP Copay	01	7a;		2		1	25.00	25.00	2		2		
H4754	012	0	1	04	01	H4754_012_0	8	3	Specialist Copay	01	5;7d;		2		1	45.00	45.00	2		2		
H4754	012	0	1	04	01	H4754_012_0	8	4	30% coinsurance - DME and Prosthetics	01	11a;11b;		2		2			2		1	0	30
H4754	012	0	1	04	01	H4754_012_0	8	5	$0 copay	11	17b;	14c;	2		2			2		2		
H4754	012	0	1	04	01	H4754_012_0	8	6	ASC	01	9b;		2		1	350.00	350.00	2		2		
H4754	801	0	1	04	01	H4754_801_0	6	1		01	6;14a;		2		2			2		1	0	0
H4754	801	0	1	04	01	H4754_801_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H4754	802	0	1	04	01	H4754_802_0	6	1		01	6;14a;		2		2			2		1	0	0
H4754	802	0	1	04	01	H4754_802_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H4875	016	1	1	04	01	H4875_016_1	5	3	0-30% coinsurance	10		14c;	2		2			2		1	0	30
H4875	016	1	1	04	01	H4875_016_1	5	2	30% coinsurance (+ physician coins.)	01	8a1;8a2;8b1;8b2;8b3;14e;		2		2			2		1	30	30
H4875	016	1	1	04	01	H4875_016_1	5	8	$0-$40 Copayment	10		16a;	2		1	0.00	40.00	2		2		
H4875	016	1	1	04	01	H4875_016_1	5	7	40% coinsurance	01	5;		2		2			2		1	40	40
H4875	016	1	1	04	01	H4875_016_1	5	6	$0 copayment	11	6;9d;	9d;	2		2			2		2		
H4875	016	1	1	04	01	H4875_016_1	5	5	$200 copayment	01	10a;		2		1	200.00	200.00	2		2		
H4875	016	1	1	04	01	H4875_016_1	5	4	0-20% coinsurance	11	15;	15;	2		2			2		1	0	20
H4875	016	1	1	04	01	H4875_016_1	5	1	30% coinsurance	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;9a;9b;9c;11a;11b;11c;12;14a;14d;16b;17a;17b;18a;	14b;	2		2			2		1	30	30
H4875	016	2	1	04	01	H4875_016_2	5	1	30% coinsurance	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;9a;9b;9c;11a;11b;11c;12;14a;14d;16b;17a;17b;18a;	14b;	2		2			2		1	30	30
H4875	016	2	1	04	01	H4875_016_2	5	7	40% coinsurance	01	5;		2		2			2		1	40	40
H4875	016	2	1	04	01	H4875_016_2	5	6	$0 copayment	11	6;9d;	9d;	2		2			2		2		
H4875	016	2	1	04	01	H4875_016_2	5	5	$200 copayment	01	10a;		2		1	200.00	200.00	2		2		
H4875	016	2	1	04	01	H4875_016_2	5	4	0-20% coinsurance	11	15;	15;	2		2			2		1	0	20
H4875	016	2	1	04	01	H4875_016_2	5	3	0-30% coinsurance	10		14c;	2		2			2		1	0	30
H4875	016	2	1	04	01	H4875_016_2	5	2	30% coinsurance (+ physician coins.)	01	8a1;8a2;8b1;8b2;8b3;14e;		2		2			2		1	30	30
H4875	016	2	1	04	01	H4875_016_2	5	8	$0-$40 Copayment	10		16a;	2		1	0.00	40.00	2		2		
H4875	016	3	1	04	01	H4875_016_3	5	3	0-30% coinsurance	10		14c;	2		2			2		1	0	30
H4875	016	3	1	04	01	H4875_016_3	5	2	30% coinsurance (+ physician coins.)	01	8a1;8a2;8b1;8b2;8b3;14e;		2		2			2		1	30	30
H4875	016	3	1	04	01	H4875_016_3	5	1	30% coinsurance	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;9a;9b;9c;11a;11b;11c;12;14a;14d;16b;17a;17b;18a;	14b;	2		2			2		1	30	30
H4875	016	3	1	04	01	H4875_016_3	5	4	0-20% coinsurance	11	15;	15;	2		2			2		1	0	20
H4875	016	3	1	04	01	H4875_016_3	5	8	$0-$40 Copayment	10		16a;	2		1	0.00	40.00	2		2		
H4875	016	3	1	04	01	H4875_016_3	5	7	40% coinsurance	01	5;		2		2			2		1	40	40
H4875	016	3	1	04	01	H4875_016_3	5	6	$0 copayment	11	6;9d;	9d;	2		2			2		2		
H4875	016	3	1	04	01	H4875_016_3	5	5	$200 copayment	01	10a;		2		1	200.00	200.00	2		2		
H4875	016	4	1	04	01	H4875_016_4	5	1	30% coinsurance	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;9a;9b;9c;11a;11b;11c;12;14a;14d;16b;17a;17b;18a;	14b;	2		2			2		1	30	30
H4875	016	4	1	04	01	H4875_016_4	5	2	30% coinsurance (+ physician coins.)	01	8a1;8a2;8b1;8b2;8b3;14e;		2		2			2		1	30	30
H4875	016	4	1	04	01	H4875_016_4	5	8	$0-$40 Copayment	10		16a;	2		1	0.00	40.00	2		2		
H4875	016	4	1	04	01	H4875_016_4	5	7	40% coinsurance	01	5;		2		2			2		1	40	40
H4875	016	4	1	04	01	H4875_016_4	5	6	$0 copayment	11	6;9d;	9d;	2		2			2		2		
H4875	016	4	1	04	01	H4875_016_4	5	5	$200 copayment	01	10a;		2		1	200.00	200.00	2		2		
H4875	016	4	1	04	01	H4875_016_4	5	4	0-20% coinsurance	11	15;	15;	2		2			2		1	0	20
H4875	016	4	1	04	01	H4875_016_4	5	3	0-30% coinsurance	10		14c;	2		2			2		1	0	30
H4875	016	5	1	04	01	H4875_016_5	5	1	30% coinsurance	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;9a;9b;9c;11a;11b;11c;12;14a;14d;16b;17a;17b;18a;	14b;	2		2			2		1	30	30
H4875	016	5	1	04	01	H4875_016_5	5	4	0-20% coinsurance	11	15;	15;	2		2			2		1	0	20
H4875	016	5	1	04	01	H4875_016_5	5	5	$200 copayment	01	10a;		2		1	200.00	200.00	2		2		
H4875	016	5	1	04	01	H4875_016_5	5	6	$0 copayment	11	6;9d;	9d;	2		2			2		2		
H4875	016	5	1	04	01	H4875_016_5	5	7	40% coinsurance	01	5;		2		2			2		1	40	40
H4875	016	5	1	04	01	H4875_016_5	5	3	0-30% coinsurance	10		14c;	2		2			2		1	0	30
H4875	016	5	1	04	01	H4875_016_5	5	2	30% coinsurance (+ physician coins.)	01	8a1;8a2;8b1;8b2;8b3;14e;		2		2			2		1	30	30
H4875	016	5	1	04	01	H4875_016_5	5	8	$0-$40 Copayment	10		16a;	2		1	0.00	40.00	2		2		
H4875	017	1	1	04	01	H4875_017_1	5	5	$100 copayment	01	10a;		2		1	100.00	100.00	2		2		
H4875	017	1	1	04	01	H4875_017_1	5	1	20% coinsurance	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;9a;9b;9c;11c;12;14a;14d;16b;17a;17b;18a;	14b;	2		2			2		1	20	20
H4875	017	1	1	04	01	H4875_017_1	5	2	20% coinsurance (+ physician coins)	01	8a1;8b1;8b2;8b3;14e;		2		2			2		1	20	20
H4875	017	1	1	04	01	H4875_017_1	5	3	30% coinsurance	01	11a;11b;		2		2			2		1	30	30
H4875	017	1	1	04	01	H4875_017_1	5	4	0%-20% coinsurance	11	15;	14c;15;	2		2			2		1	0	20
H4875	017	1	1	04	01	H4875_017_1	5	6	$0 copayment	11	6;9d;	9d;	2		2			2		2		
H4875	017	1	1	04	01	H4875_017_1	5	7	40% coinsurance	01	5;		2		2			2		1	40	40
H4875	017	1	1	04	01	H4875_017_1	5	8	$0-$40 Copayment	10		16a;	2		1	0.00	40.00	2		2		
H4875	017	2	1	04	01	H4875_017_2	5	7	40% coinsurance	01	5;		2		2			2		1	40	40
H4875	017	2	1	04	01	H4875_017_2	5	6	$0 copayment	11	6;9d;	9d;	2		2			2		2		
H4875	017	2	1	04	01	H4875_017_2	5	5	$100 copayment	01	10a;		2		1	100.00	100.00	2		2		
H4875	017	2	1	04	01	H4875_017_2	5	4	0%-20% coinsurance	11	15;	14c;15;	2		2			2		1	0	20
H4875	017	2	1	04	01	H4875_017_2	5	3	30% coinsurance	01	11a;11b;		2		2			2		1	30	30
H4875	017	2	1	04	01	H4875_017_2	5	2	20% coinsurance (+ physician coins)	01	8a1;8b1;8b2;8b3;14e;		2		2			2		1	20	20
H4875	017	2	1	04	01	H4875_017_2	5	1	20% coinsurance	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;9a;9b;9c;11c;12;14a;14d;16b;17a;17b;18a;	14b;	2		2			2		1	20	20
H4875	017	2	1	04	01	H4875_017_2	5	8	$0-$40 Copayment	10		16a;	2		1	0.00	40.00	2		2		
H4875	017	3	1	04	01	H4875_017_3	5	7	40% coinsurance	01	5;		2		2			2		1	40	40
H4875	017	3	1	04	01	H4875_017_3	5	6	$0 copayment	11	6;9d;	9d;	2		2			2		2		
H4875	017	3	1	04	01	H4875_017_3	5	5	$100 copayment	01	10a;		2		1	100.00	100.00	2		2		
H4875	017	3	1	04	01	H4875_017_3	5	4	0%-20% coinsurance	11	15;	14c;15;	2		2			2		1	0	20
H4875	017	3	1	04	01	H4875_017_3	5	3	30% coinsurance	01	11a;11b;		2		2			2		1	30	30
H4875	017	3	1	04	01	H4875_017_3	5	2	20% coinsurance (+ physician coins)	01	8a1;8b1;8b2;8b3;14e;		2		2			2		1	20	20
H4875	017	3	1	04	01	H4875_017_3	5	1	20% coinsurance	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;9a;9b;9c;11c;12;14a;14d;16b;17a;17b;18a;	14b;	2		2			2		1	20	20
H4875	017	3	1	04	01	H4875_017_3	5	8	$0-$40 Copayment	10		16a;	2		1	0.00	40.00	2		2		
H4875	017	4	1	04	01	H4875_017_4	5	1	20% coinsurance	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;9a;9b;9c;11c;12;14a;14d;16b;17a;17b;18a;	14b;	2		2			2		1	20	20
H4875	017	4	1	04	01	H4875_017_4	5	2	20% coinsurance (+ physician coins)	01	8a1;8b1;8b2;8b3;14e;		2		2			2		1	20	20
H4875	017	4	1	04	01	H4875_017_4	5	8	$0-$40 Copayment	10		16a;	2		1	0.00	40.00	2		2		
H4875	017	4	1	04	01	H4875_017_4	5	7	40% coinsurance	01	5;		2		2			2		1	40	40
H4875	017	4	1	04	01	H4875_017_4	5	6	$0 copayment	11	6;9d;	9d;	2		2			2		2		
H4875	017	4	1	04	01	H4875_017_4	5	5	$100 copayment	01	10a;		2		1	100.00	100.00	2		2		
H4875	017	4	1	04	01	H4875_017_4	5	4	0%-20% coinsurance	11	15;	14c;15;	2		2			2		1	0	20
H4875	017	4	1	04	01	H4875_017_4	5	3	30% coinsurance	01	11a;11b;		2		2			2		1	30	30
H4875	017	5	1	04	01	H4875_017_5	5	1	20% coinsurance	11	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;9a;9b;9c;11c;12;14a;14d;16b;17a;17b;18a;	14b;	2		2			2		1	20	20
H4875	017	5	1	04	01	H4875_017_5	5	7	40% coinsurance	01	5;		2		2			2		1	40	40
H4875	017	5	1	04	01	H4875_017_5	5	6	$0 copayment	11	6;9d;	9d;	2		2			2		2		
H4875	017	5	1	04	01	H4875_017_5	5	5	$100 copayment	01	10a;		2		1	100.00	100.00	2		2		
H4875	017	5	1	04	01	H4875_017_5	5	4	0%-20% coinsurance	11	15;	14c;15;	2		2			2		1	0	20
H4875	017	5	1	04	01	H4875_017_5	5	3	30% coinsurance	01	11a;11b;		2		2			2		1	30	30
H4875	017	5	1	04	01	H4875_017_5	5	2	20% coinsurance (+ physician coins)	01	8a1;8b1;8b2;8b3;14e;		2		2			2		1	20	20
H4875	017	5	1	04	01	H4875_017_5	5	8	$0-$40 Copayment	10		16a;	2		1	0.00	40.00	2		2		
H4875	018	1	1	04	01	H4875_018_1	6	3	30% coinsurance	01	11a;11b;		2		2			2		1	30	30
H4875	018	1	1	04	01	H4875_018_1	6	4	0%-40% coinsurance	10		14c;	2		2			2		1	0	40
H4875	018	1	1	04	01	H4875_018_1	6	5	0-20% coinsurance	11	15;	15;	2		2			2		1	0	20
H4875	018	1	1	04	01	H4875_018_1	6	6	$200 copayment	01	10a;		2		1	200.00	200.00	2		2		
H4875	018	1	1	04	01	H4875_018_1	6	7	$0 copayment	11	6;9d;	9d;	2		1	0.00	0.00	2		2		
H4875	018	1	1	04	01	H4875_018_1	6	1	40% coinsurance	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;9a;9b;9c;11c;12;14a;14d;16b;17a;17b;18a;	14b;	2		2			2		1	40	40
H4875	018	1	1	04	01	H4875_018_1	6	2	40% coinsurance (+ physician coins)	01	8a1;8a2;8b1;8b2;8b3;14e;		2		2			2		1	40	40
H4875	018	2	1	04	01	H4875_018_2	5	1	40% coinsurance	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;9a;9b;9c;11c;12;14a;14d;16b;17a;17b;18a;	14b;	2		2			2		1	40	40
H4875	018	2	1	04	01	H4875_018_2	5	2	40% coinsurance (+ physician coins)	01	8a1;8a2;8b1;8b2;8b3;14e;		2		2			2		1	40	40
H4875	018	2	1	04	01	H4875_018_2	5	3	30% coinsurance	01	11a;11b;		2		2			2		1	30	30
H4875	018	2	1	04	01	H4875_018_2	5	4	0%-40% coinsurance	10		14c;	2		2			2		1	0	40
H4875	018	2	1	04	01	H4875_018_2	5	5	0-20% coinsurance	11	15;	15;	2		2			2		1	0	20
H4875	018	2	1	04	01	H4875_018_2	5	6	$200 copayment	01	10a;		2		1	200.00	200.00	2		2		
H4875	018	2	1	04	01	H4875_018_2	5	7	$0 copayment	11	6;9d;	9d;	2		1	0.00	0.00	2		2		
H4875	018	3	1	04	01	H4875_018_3	5	1	40% coinsurance	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;9a;9b;9c;11c;12;14a;14d;16b;17a;17b;18a;	14b;	2		2			2		1	40	40
H4875	018	3	1	04	01	H4875_018_3	5	2	40% coinsurance (+ physician coins)	01	8a1;8a2;8b1;8b2;8b3;14e;		2		2			2		1	40	40
H4875	018	3	1	04	01	H4875_018_3	5	3	30% coinsurance	01	11a;11b;		2		2			2		1	30	30
H4875	018	3	1	04	01	H4875_018_3	5	4	0%-40% coinsurance	10		14c;	2		2			2		1	0	40
H4875	018	3	1	04	01	H4875_018_3	5	5	0-20% coinsurance	11	15;	15;	2		2			2		1	0	20
H4875	018	3	1	04	01	H4875_018_3	5	6	$200 copayment	01	10a;		2		1	200.00	200.00	2		2		
H4875	018	3	1	04	01	H4875_018_3	5	7	$0 copayment	11	6;9d;	9d;	2		1	0.00	0.00	2		2		
H4875	018	4	1	04	01	H4875_018_4	5	1	40% coinsurance	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;9a;9b;9c;11c;12;14a;14d;16b;17a;17b;18a;	14b;	2		2			2		1	40	40
H4875	018	4	1	04	01	H4875_018_4	5	2	40% coinsurance (+ physician coins)	01	8a1;8a2;8b1;8b2;8b3;14e;		2		2			2		1	40	40
H4875	018	4	1	04	01	H4875_018_4	5	7	$0 copayment	11	6;9d;	9d;	2		1	0.00	0.00	2		2		
H4875	018	4	1	04	01	H4875_018_4	5	6	$200 copayment	01	10a;		2		1	200.00	200.00	2		2		
H4875	018	4	1	04	01	H4875_018_4	5	5	0-20% coinsurance	11	15;	15;	2		2			2		1	0	20
H4875	018	4	1	04	01	H4875_018_4	5	4	0%-40% coinsurance	10		14c;	2		2			2		1	0	40
H4875	018	4	1	04	01	H4875_018_4	5	3	30% coinsurance	01	11a;11b;		2		2			2		1	30	30
H4875	018	5	1	04	01	H4875_018_5	5	6	$200 copayment	01	10a;		2		1	200.00	200.00	2		2		
H4875	018	5	1	04	01	H4875_018_5	5	2	40% coinsurance (+ physician coins)	01	8a1;8a2;8b1;8b2;8b3;14e;		2		2			2		1	40	40
H4875	018	5	1	04	01	H4875_018_5	5	3	30% coinsurance	01	11a;11b;		2		2			2		1	30	30
H4875	018	5	1	04	01	H4875_018_5	5	4	0%-40% coinsurance	10		14c;	2		2			2		1	0	40
H4875	018	5	1	04	01	H4875_018_5	5	7	$0 copayment	11	6;9d;	9d;	2		1	0.00	0.00	2		2		
H4875	018	5	1	04	01	H4875_018_5	5	1	40% coinsurance	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;9a;9b;9c;11c;12;14a;14d;16b;17a;17b;18a;	14b;	2		2			2		1	40	40
H4875	018	5	1	04	01	H4875_018_5	5	5	0-20% coinsurance	11	15;	15;	2		2			2		1	0	20
H4875	803	0	1	04	01	H4875_803_0	5	1	20% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;15;16b;17b;18a;	14b;	2		2			2		1	20	20
H4875	803	0	1	04	01	H4875_803_0	5	2	20% Coinsurance (+ physician coins)	01	8a1;8b1;8b2;8b3;14e;17a;		2		2			2		1	20	20
H4875	804	0	1	04	01	H4875_804_0	5	2	20% Coinsurance (+ physician coins)	01	8a1;8b1;8b2;8b3;14e;17a;		2		2			2		1	20	20
H4875	804	0	1	04	01	H4875_804_0	5	1	20% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;15;16b;17b;18a;	14b;	2		2			2		1	20	20
H4876	001	0	1	04	01	H4876_001_0	7	1		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	16a;17a;	2		2			2		1	20	20
H4876	001	0	1	04	01	H4876_001_0	7	2		10		13b;	1	20.00	2			2		2		
H4876	001	0	1	04	01	H4876_001_0	7	3		10		18b;	2		2			2		2		
H4876	001	0	1	04	01	H4876_001_0	7	4		10		16b;	1	500.00	2			2		2		
H4876	001	0	1	04	01	H4876_001_0	7	5		10		17b;	2		2			2		1	20	20
H4876	001	0	1	04	01	H4876_001_0	7	6		10		14c;	1	300.00	2			2		1	20	20
H4876	801	0	1	04	01	H4876_801_0	4	1		01	6;14a;		2		2			2		1	0	0
H4876	801	0	1	04	01	H4876_801_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H4876	802	0	1	04	01	H4876_802_0	4	1		01	6;14a;		2		2			2		1	0	0
H4876	802	0	1	04	01	H4876_802_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H4909	014	0	1	04	01	H4909_014_0	10	1	35%	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14d;14e;17a;17b;18a;		2		2			2		1	35	35
H4909	014	0	1	04	01	H4909_014_0	10	10	14C Eligible Supplemental Benefits	10		14c;	1	95.00	1	0.00	0.00	2		2		
H4909	014	0	1	04	01	H4909_014_0	10	9	25%	01	15;		2		2			2		1	25	25
H4909	014	0	1	04	01	H4909_014_0	10	8	35%	01	14a;		2		2			2		1	35	35
H4909	014	0	1	04	01	H4909_014_0	10	7	20% - $150	01	10a;		2		1	150.00	150.00	2		1	20	20
H4909	014	0	1	04	01	H4909_014_0	10	6	$0	11	9d;16b;	9d;17a;	2		1	0.00	0.00	2		2		
H4909	014	0	1	04	01	H4909_014_0	10	5	20%	11	8b2;12;	16a;	2		2			2		1	20	20
H4909	014	0	1	04	01	H4909_014_0	10	2	$30	11	7a;7g;	14b;	2		1	30.00	30.00	2		2		
H4909	014	0	1	04	01	H4909_014_0	10	3	$50	01	7b;7c;7d;7e;7f;7h;7i;		2		1	50.00	50.00	2		2		
H4909	014	0	1	04	01	H4909_014_0	10	4	30%	01	8a1;8a2;8b1;8b3;		2		2			2		1	30	30
H4909	804	0	1	04	01	H4909_804_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H4909	804	0	1	04	01	H4909_804_0	4	1		01	6;14a;		2		2			2		1	0	0
H4909	805	0	1	04	01	H4909_805_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H4909	805	0	1	04	01	H4909_805_0	4	1		01	6;14a;		2		2			2		1	0	0
H4909	806	0	1	04	01	H4909_806_0	4	1		01	6;14a;		2		2			2		1	0	0
H4909	806	0	1	04	01	H4909_806_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5009	001	0	1	04	01	H5009_001_0	4	2	$40 copay	10		17a;	2		1	40.00	40.00	2		2		
H5009	001	0	1	04	01	H5009_001_0	4	3	$300 copay	01	10a;		2		1	300.00	300.00	2		2		
H5009	001	0	1	04	01	H5009_001_0	4	1	$0 copay	10		14c;17b;	2		2			2		2		
H5009	001	0	1	04	01	H5009_001_0	4	4	30% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;	2		2			2		1	30	30
H5009	001	0	1	04	01	H5009_001_0	4	5	50% coinsurance	10		16a;	2		2			2		1	50	50
H5009	002	0	1	04	01	H5009_002_0	5	2	$40 copay	10		17a;	2		1	40.00	40.00	2		2		
H5009	002	0	1	04	01	H5009_002_0	5	1	$0 copay	10		14c;17b;	2		2			2		2		
H5009	002	0	1	04	01	H5009_002_0	5	3	$300 copay	01	10a;		2		1	300.00	300.00	2		2		
H5009	002	0	1	04	01	H5009_002_0	5	6	$599 to $899 copay	10		18b;	2		1	599.00	899.00	2		2		
H5009	002	0	1	04	01	H5009_002_0	5	5	50% coinsurance	10		16a;	2		2			2		1	50	50
H5009	002	0	1	04	01	H5009_002_0	5	4	30% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;	2		2			2		1	30	30
H5009	801	0	1	04	01	H5009_801_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5009	801	0	1	04	01	H5009_801_0	5	1		01	6;14a;		2		2			2		1	0	0
H5009	802	0	1	04	01	H5009_802_0	6	1		01	6;14a;		2		2			2		1	0	0
H5009	802	0	1	04	01	H5009_802_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5010	001	0	1	04	01	H5010_001_0	5	3	$300 copay	01	10a;		2		1	300.00	300.00	2		2		
H5010	001	0	1	04	01	H5010_001_0	5	2	$40 copay	10		17a;	2		1	40.00	40.00	2		2		
H5010	001	0	1	04	01	H5010_001_0	5	1	$0 copay	10		14c;17b;	2		2			2		2		
H5010	001	0	1	04	01	H5010_001_0	5	4	30% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;	2		2			2		1	30	30
H5010	001	0	1	04	01	H5010_001_0	5	5	50% coinsurance	10		16a;	2		2			2		1	50	50
H5010	002	0	1	04	01	H5010_002_0	6	3	$300 copay	01	10a;		2		1	300.00	300.00	2		2		
H5010	002	0	1	04	01	H5010_002_0	6	2	$40 copay	10		17a;	2		1	40.00	40.00	2		2		
H5010	002	0	1	04	01	H5010_002_0	6	1	$0 copay	10		14c;17b;	2		2			2		2		
H5010	002	0	1	04	01	H5010_002_0	6	4	30% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;	2		2			2		1	30	30
H5010	002	0	1	04	01	H5010_002_0	6	5	50% coinsurance	10		16a;	2		2			2		1	50	50
H5010	004	0	1	04	01	H5010_004_0	7	3	$250 copay	01	10a;		2		1	250.00	250.00	2		2		
H5010	004	0	1	04	01	H5010_004_0	7	2	$30 copay	10		17a;	2		1	30.00	30.00	2		2		
H5010	004	0	1	04	01	H5010_004_0	7	1	$0 copay	10		14c;17b;	2		2			2		2		
H5010	004	0	1	04	01	H5010_004_0	7	4	30% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;	2		2			2		1	30	30
H5010	004	0	1	04	01	H5010_004_0	7	6	$599 or $899 copay	10		18b;	2		1	599.00	899.00	2		2		
H5010	004	0	1	04	01	H5010_004_0	7	5	50% coinsurance	10		16a;	2		2			2		1	50	50
H5042	801	0	1	04	01	H5042_801_0	7	1		01	6;14a;		2		2			2		1	0	0
H5042	801	0	1	04	01	H5042_801_0	7	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5042	802	0	1	04	01	H5042_802_0	7	1		01	6;14a;		2		2			2		1	0	0
H5042	802	0	1	04	01	H5042_802_0	7	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5042	803	0	1	04	01	H5042_803_0	7	1		01	6;14a;		2		2			2		1	0	0
H5042	803	0	1	04	01	H5042_803_0	7	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5106	013	0	1	04	01	H5106_013_0	9	10	Routine Eye Exam	10		17a;	2		1	40.00	40.00	2		2		
H5106	013	0	1	04	01	H5106_013_0	9	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;16b;18a;	7b;7f;9d;18a;	2		2			2		1	30	30
H5106	013	0	1	04	01	H5106_013_0	9	2	Preventive Services and Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2		2		
H5106	013	0	1	04	01	H5106_013_0	9	3	Ambulance	01	10a;		2		1	175.00	175.00	2		1	30	30
H5106	013	0	1	04	01	H5106_013_0	9	9	End Stage Renal and Part B Drugs	01	12;15;		2		2			2		1	0	30
H5106	013	0	1	04	01	H5106_013_0	9	5	Fitness Benefit	10		14c;	2		2			1	500.00	1	50	50
H5106	013	0	1	04	01	H5106_013_0	9	6	Primary Care Physician	01	7a;		2		1	30.00	30.00	2		2		
H5106	013	0	1	04	01	H5106_013_0	9	7	Specialist and NonRoutine Eye Exam	01	7d;17a;		2		1	45.00	45.00	2		2		
H5106	013	0	1	04	01	H5106_013_0	9	8	Hearing Aids	10		18b;	2		1	699.00	999.00	2		2		
H5106	013	0	1	04	01	H5106_013_0	9	4	Transportation and Preventive Dental	10		10b;16a;	2		2			2		1	50	50
H5106	027	0	1	04	01	H5106_027_0	10	10	Routine Eye Exam	10		17a;	2		1	40.00	40.00	2		2		
H5106	027	0	1	04	01	H5106_027_0	10	1	Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;16b;18a;	7b;7f;9d;18a;	2		2			2		1	30	30
H5106	027	0	1	04	01	H5106_027_0	10	2	Preventive Services and Eyewear	11	14a;14d;14e;17b;	17b;	2		2			2		2		
H5106	027	0	1	04	01	H5106_027_0	10	3	Ambulance	01	10a;		2		1	200.00	200.00	2		1	30	30
H5106	027	0	1	04	01	H5106_027_0	10	4	Transportation and Preventive Dental	10		10b;16a;	2		2			2		1	50	50
H5106	027	0	1	04	01	H5106_027_0	10	5	Fitness Benefit	10		14c;	2		2			1	500.00	1	50	50
H5106	027	0	1	04	01	H5106_027_0	10	9	End Stage Renal and Part B Drugs	01	12;15;		2		2			2		1	0	30
H5106	027	0	1	04	01	H5106_027_0	10	8	Hearing Aids	10		18b;	2		1	699.00	999.00	2		2		
H5106	027	0	1	04	01	H5106_027_0	10	7	Specialist and NonRoutine Eye Exam	01	7d;17a;		2		1	50.00	50.00	2		2		
H5106	027	0	1	04	01	H5106_027_0	10	6	Primary Care Physician	01	7a;		2		1	30.00	30.00	2		2		
H5106	806	0	1	04	01	H5106_806_0	4	1		01	6;14a;		2		2			2		1	0	0
H5106	806	0	1	04	01	H5106_806_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5106	807	0	1	04	01	H5106_807_0	4	1		01	6;14a;		2		2			2		1	0	0
H5106	807	0	1	04	01	H5106_807_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5106	808	0	1	04	01	H5106_808_0	4	1		01	6;14a;		2		2			2		1	0	0
H5106	808	0	1	04	01	H5106_808_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5141	001	0	1	04	01	H5141_001_0	18	9	OTC Card - Quarterly Benefit	10		13b;	1	21.00	2			2		2		
H5141	001	0	1	04	01	H5141_001_0	18	8	Non-Medicare Eyewear	10		17b;	2		1	40.00	40.00	2		2		
H5141	001	0	1	04	01	H5141_001_0	18	7	Copayment none	11	6;7a;8a1;8a2;9d;11c;14a;14d;14e;16b;17b;	17a;	2		2			2		2		
H5141	001	0	1	04	01	H5141_001_0	18	6	Other Healthcare Professional	01	3-1;3-2;3-3;5;7b;7c;7e;7f;7g;7h;7i;9c;17a;18a;		2		1	20.00	20.00	2		2		
H5141	001	0	1	04	01	H5141_001_0	18	5	Specialist Physician	01	7d;		2		1	15.00	15.00	2		2		
H5141	001	0	1	04	01	H5141_001_0	18	4	Therapeutic Radiological Services, X-Ray	01	8b2;8b3;		2		1	30.00	30.00	2		2		
H5141	001	0	1	04	01	H5141_001_0	18	3	MRI, PET, CAT	01	8b1;		2		1	150.00	150.00	2		2		
H5141	001	0	1	04	01	H5141_001_0	18	2	Copayment - 20%	01	11a;11b;12;15;		2		2			2		1	20	20
H5141	001	0	1	04	01	H5141_001_0	18	1	ASC, Observation, Outpatient	01	9a;9b;		2		1	90.00	290.00	2		2		
H5141	001	0	1	04	01	H5141_001_0	18	10	Eligible Supplemental Benefits	10		14c;	2		2			2		2		
H5141	001	0	1	04	01	H5141_001_0	18	11	Ambulance Services	01	10a;		2		1	200.00	200.00	2		2		
H5141	004	0	1	04	01	H5141_004_0	16	2	Copayment - 20%	01	11a;11b;12;15;		2		2			2		1	20	20
H5141	004	0	1	04	01	H5141_004_0	16	9	Ambulance Services	01	10a;		2		1	250.00	250.00	2		2		
H5141	004	0	1	04	01	H5141_004_0	16	10	Eligible Supplemental Benefits	10		14c;	2		2			2		2		
H5141	004	0	1	04	01	H5141_004_0	16	3	MRI, PET, CAT	01	8b1;		2		1	150.00	150.00	2		2		
H5141	004	0	1	04	01	H5141_004_0	16	1	ASC, Observation, Outpatient	01	9a;9b;		2		1	90.00	325.00	2		2		
H5141	004	0	1	04	01	H5141_004_0	16	5	Specialist Physician	01	7d;		2		1	15.00	15.00	2		2		
H5141	004	0	1	04	01	H5141_004_0	16	6	Other Healthcare Professional	01	3-1;3-2;3-3;5;7b;7c;7e;7f;7g;7h;7i;9c;17a;18a;		2		1	20.00	20.00	2		2		
H5141	004	0	1	04	01	H5141_004_0	16	7	Copayment none	11	6;7a;8a1;8a2;9d;11c;14a;14d;14e;16b;17b;	17a;	2		2			2		2		
H5141	004	0	1	04	01	H5141_004_0	16	8	Non-Medicare Eyewear	10		17b;	2		1	40.00	40.00	2		2		
H5141	004	0	1	04	01	H5141_004_0	16	4	Therapeutic Radiological Services, X-Ray	01	8b2;8b3;		2		1	30.00	30.00	2		2		
H5141	006	0	1	04	01	H5141_006_0	13	1	Medicare Covered Benefits	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;		2		2			2		2		
H5141	006	0	1	04	01	H5141_006_0	13	3	Eyewear	10		17b;	2		1	40.00	40.00	2		2		
H5141	006	0	1	04	01	H5141_006_0	13	4	Routine Eye Exam	10		17a;	2		2			2		2		
H5141	006	0	1	04	01	H5141_006_0	13	2	Supplemental Benefit	10		14c;	2		2			2		2		
H5141	007	0	1	04	01	H5141_007_0	15	1	ASC, Observation, Outpatient	01	9a;9b;		2		1	90.00	175.00	2		2		
H5141	007	0	1	04	01	H5141_007_0	15	10	Eligible Supplemental Benefits	10		14c;	2		2			2		2		
H5141	007	0	1	04	01	H5141_007_0	15	2	Copayment - 20%	01	11a;11b;12;15;		2		2			2		1	20	20
H5141	007	0	1	04	01	H5141_007_0	15	3	MRI, PET, CAT	01	8b1;		2		1	150.00	150.00	2		2		
H5141	007	0	1	04	01	H5141_007_0	15	9	Ambulance Services	01	10a;		2		1	200.00	200.00	2		2		
H5141	007	0	1	04	01	H5141_007_0	15	5	Specialist Physician	01	7d;		2		1	0.00	0.00	2		2		
H5141	007	0	1	04	01	H5141_007_0	15	6	Other Healthcare Professional	01	3-1;3-2;3-3;5;7b;7c;7e;7f;7g;7h;7i;9c;17a;18a;		2		1	10.00	10.00	2		2		
H5141	007	0	1	04	01	H5141_007_0	15	7	Copayment none	11	6;7a;8a1;8a2;9d;11c;14a;14d;14e;16b;17b;	17a;	2		2			2		2		
H5141	007	0	1	04	01	H5141_007_0	15	8	Non-Medicare Eyewear	10		17b;	2		1	40.00	40.00	2		2		
H5141	007	0	1	04	01	H5141_007_0	15	4	Therapeutic Radiological Services, X-Ray	01	8b2;8b3;		2		1	20.00	20.00	2		2		
H5215	001	0	1	04	01	H5215_001_0	6	1	$250	01	10a;		2		1	250.00	250.00	2		2		
H5215	001	0	1	04	01	H5215_001_0	6	2	$36 Copay	10		3-1;	2		1	36.00	36.00	2		2		
H5215	001	0	1	04	01	H5215_001_0	6	3	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	13d;14b;	2		2			2		1	50	50
H5215	001	0	1	04	01	H5215_001_0	6	4	50% + $2640 limit	10		14c;	1	2640.00	2			2		1	50	50
H5215	002	0	1	04	01	H5215_002_0	8	1	$250	01	10a;		2		1	250.00	250.00	2		2		
H5215	002	0	1	04	01	H5215_002_0	8	2	$36 Copay	10		3-1;	2		1	36.00	36.00	2		2		
H5215	002	0	1	04	01	H5215_002_0	8	3	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	13d;14b;	2		2			2		1	50	50
H5215	002	0	1	04	01	H5215_002_0	8	4	50% + $2640 limit	10		14c;	1	2640.00	2			2		1	50	50
H5215	005	0	1	04	01	H5215_005_0	7	4	$0 + limit	10		18b;	2		2			2		2		
H5215	005	0	1	04	01	H5215_005_0	7	5	50% + $2640 limit	10		14c;	1	2640.00	2			2		1	50	50
H5215	005	0	1	04	01	H5215_005_0	7	1	$0	01	10a;		2		2			2		2		
H5215	005	0	1	04	01	H5215_005_0	7	2	$36 Copay	10		3-1;	2		1	36.00	36.00	2		2		
H5215	005	0	1	04	01	H5215_005_0	7	3	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	13d;14b;18a;	2		2			2		1	50	50
H5215	006	0	1	04	01	H5215_006_0	7	2	$36 Copay	10		3-1;	2		1	36.00	36.00	2		2		
H5215	006	0	1	04	01	H5215_006_0	7	3	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	13d;14b;18a;	2		2			2		1	50	50
H5215	006	0	1	04	01	H5215_006_0	7	5	50% + $2640 limit	10		14c;	1	2640.00	2			2		1	50	50
H5215	006	0	1	04	01	H5215_006_0	7	4	$0 + limit	10		18b;	2		2			2		2		
H5215	006	0	1	04	01	H5215_006_0	7	1	$0	01	10a;		2		2			2		2		
H5215	007	0	1	04	01	H5215_007_0	9	6	0% + $1500 limit	10		16a;	2		2			2		2		
H5215	007	0	1	04	01	H5215_007_0	9	7	0-50% + $2640 limit	10		14c;	1	2640.00	2			2		1	0	50
H5215	007	0	1	04	01	H5215_007_0	9	5	$0 + $425 limit	10		17b;	2		2			2		2		
H5215	007	0	1	04	01	H5215_007_0	9	4	20-50%	10		16b;	2		2			2		1	20	50
H5215	007	0	1	04	01	H5215_007_0	9	3	20%	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	13d;	2		2			2		1	20	20
H5215	007	0	1	04	01	H5215_007_0	9	8	0% + $170 limit	10		13b;	1	170.00	2			2		2		
H5215	007	0	1	04	01	H5215_007_0	9	1	$0	11	6;	17a;	2		2			2		2		
H5215	007	0	1	04	01	H5215_007_0	9	2	$36	10		3-1;	2		1	36.00	36.00	2		2		
H5215	008	0	1	04	01	H5215_008_0	10	11	20%	01	12;		2		2			2		1	20	20
H5215	008	0	1	04	01	H5215_008_0	10	10	$250	01	10a;		2		1	250.00	250.00	2		2		
H5215	008	0	1	04	01	H5215_008_0	10	1	$0	10		13d;	2		2			2		2		
H5215	008	0	1	04	01	H5215_008_0	10	12	30%	01	6;8b1;8b2;		2		2			2		1	30	30
H5215	008	0	1	04	01	H5215_008_0	10	9	$100	01	5;		2		1	100.00	100.00	2		2		
H5215	008	0	1	04	01	H5215_008_0	10	8	$55	01	7d;7f;7g;		2		1	55.00	55.00	2		2		
H5215	008	0	1	04	01	H5215_008_0	10	7	$50	01	7b;8b3;17a;		2		1	50.00	50.00	2		2		
H5215	008	0	1	04	01	H5215_008_0	10	6	$45	01	7c;7e;7h;7i;9c;16b;17b;18a;		2		1	45.00	45.00	2		2		
H5215	008	0	1	04	01	H5215_008_0	10	5	$40	01	3-1;3-2;3-3;9d;		2		1	40.00	40.00	2		2		
H5215	008	0	1	04	01	H5215_008_0	10	13	45%	01	9b;		2		2			2		1	45	45
H5215	008	0	1	04	01	H5215_008_0	10	14	50%	01	9a;11a;11b;11c;15;		2		2			2		1	50	50
H5215	008	0	1	04	01	H5215_008_0	10	15	50% + $2640 limit	10		14c;	1	2640.00	2			2		1	50	50
H5215	008	0	1	04	01	H5215_008_0	10	2	$20-$50	01	8a1;8a2;14d;14e;		2		1	20.00	50.00	2		2		
H5215	008	0	1	04	01	H5215_008_0	10	3	$30	11	7a;14a;	14b;	2		1	30.00	30.00	2		2		
H5215	008	0	1	04	01	H5215_008_0	10	4	$36	10		3-1;	2		1	36.00	36.00	2		2		
H5215	806	0	1	04	01	H5215_806_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5215	806	0	1	04	01	H5215_806_0	6	1		01	6;14a;		2		2			2		1	0	0
H5215	807	0	1	04	01	H5215_807_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5215	807	0	1	04	01	H5215_807_0	5	1		01	6;14a;		2		2			2		1	0	0
H5215	808	0	1	04	01	H5215_808_0	6	1		01	6;14a;		2		2			2		1	0	0
H5215	808	0	1	04	01	H5215_808_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5216	001	0	1	04	01	H5216_001_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H5216	001	0	1	04	01	H5216_001_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5216	001	0	1	04	01	H5216_001_0	3	8		10		13b;	1	25.00	2			2		1	50	50
H5216	001	0	1	04	01	H5216_001_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;15;16b;17a;18a;	13c;13d;14b;14c;16a;16b;	2		2			2		1	50	50
H5216	001	0	1	04	01	H5216_001_0	3	6		01	11c;		2		2			2		1	30	50
H5216	001	0	1	04	01	H5216_001_0	3	5		01	11a;		2		2			2		1	30	30
H5216	001	0	1	04	01	H5216_001_0	3	4		01	12;		2		2			2		1	20	20
H5216	001	0	1	04	01	H5216_001_0	3	3		01	14a;		2		2			2		1	0	50
H5216	003	0	1	04	01	H5216_003_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H5216	003	0	1	04	01	H5216_003_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;15;16b;17a;18a;	13c;13d;14b;14c;16a;16b;	2		2			2		1	50	50
H5216	003	0	1	04	01	H5216_003_0	3	6		01	11c;		2		2			2		1	30	40
H5216	003	0	1	04	01	H5216_003_0	3	5		01	11a;		2		2			2		1	25	25
H5216	003	0	1	04	01	H5216_003_0	3	4		01	12;		2		2			2		1	20	20
H5216	003	0	1	04	01	H5216_003_0	3	3		01	14a;		2		2			2		1	0	50
H5216	003	0	1	04	01	H5216_003_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5216	003	0	1	04	01	H5216_003_0	3	8		10		13b;	1	25.00	2			2		1	50	50
H5216	006	0	1	04	01	H5216_006_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H5216	006	0	1	04	01	H5216_006_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5216	006	0	1	04	01	H5216_006_0	3	7		10		13b;	1	25.00	2			2		1	50	50
H5216	006	0	1	04	01	H5216_006_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13c;13d;14b;14c;	2		2			2		1	50	50
H5216	006	0	1	04	01	H5216_006_0	3	5		01	11a;		2		2			2		1	30	30
H5216	006	0	1	04	01	H5216_006_0	3	4		01	12;		2		2			2		1	20	20
H5216	006	0	1	04	01	H5216_006_0	3	3		01	14a;		2		2			2		1	0	50
H5216	009	0	1	04	01	H5216_009_0	3	6		10		13b;	1	25.00	2			2		1	50	50
H5216	009	0	1	04	01	H5216_009_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13c;13d;14b;14c;16a;16b;	2		2			2		1	50	50
H5216	009	0	1	04	01	H5216_009_0	3	4		01	11a;12;		2		2			2		1	20	20
H5216	009	0	1	04	01	H5216_009_0	3	3		01	14a;		2		2			2		1	0	50
H5216	009	0	1	04	01	H5216_009_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5216	009	0	1	04	01	H5216_009_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H5216	010	0	1	04	01	H5216_010_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5216	010	0	1	04	01	H5216_010_0	3	3		01	14a;		2		2			2		1	0	50
H5216	010	0	1	04	01	H5216_010_0	3	4		01	12;		2		2			2		1	20	20
H5216	010	0	1	04	01	H5216_010_0	3	5		01	11a;		2		2			2		1	25	25
H5216	010	0	1	04	01	H5216_010_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13c;13d;14b;14c;16a;16b;	2		2			2		1	50	50
H5216	010	0	1	04	01	H5216_010_0	3	7		10		13b;	1	25.00	2			2		1	50	50
H5216	010	0	1	04	01	H5216_010_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H5415	056	0	1	04	01	H5415_056_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H5415	056	0	1	04	01	H5415_056_0	3	10		01	14a;		2		1	0.00	50.00	2		1	50	50
H5415	056	0	1	04	01	H5415_056_0	3	11		11	3-1;3-2;3-3;7c;7i;8a1;8a2;8b1;8b2;8b3;9c;14e;	13d;	2		1	50.00	50.00	2		1	50	50
H5415	056	0	1	04	01	H5415_056_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5415	056	0	1	04	01	H5415_056_0	3	3		11	7e;7h;	14b;	2		1	40.00	40.00	2		2		
H5415	056	0	1	04	01	H5415_056_0	3	9		10		13b;	1	10.00	2			2		1	50	50
H5415	056	0	1	04	01	H5415_056_0	3	5		01	12;		2		2			2		1	0	20
H5415	056	0	1	04	01	H5415_056_0	3	6		01	15;		2		2			2		1	20	50
H5415	056	0	1	04	01	H5415_056_0	3	7		01	11b;		2		2			2		1	25	25
H5415	056	0	1	04	01	H5415_056_0	3	8		11	5;6;9a;9b;11a;11c;	13c;14c;16a;16b;	2		2			2		1	50	50
H5415	056	0	1	04	01	H5415_056_0	3	4		01	7a;7b;7d;7f;7g;14d;16b;17a;18a;		2		1	50.00	50.00	2		2		
H5415	070	0	1	04	01	H5415_070_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H5415	070	0	1	04	01	H5415_070_0	3	10		01	14a;		2		1	0.00	40.00	2		1	50	50
H5415	070	0	1	04	01	H5415_070_0	3	11		11	3-1;3-2;3-3;7c;7i;8a2;8b1;8b2;8b3;9c;14e;	13d;	2		1	40.00	40.00	2		1	50	50
H5415	070	0	1	04	01	H5415_070_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5415	070	0	1	04	01	H5415_070_0	3	3		11	7a;7b;7d;7e;7f;7g;7h;14d;16b;17a;18a;	14b;	2		1	40.00	40.00	2		2		
H5415	070	0	1	04	01	H5415_070_0	3	4		01	12;		2		2			2		1	20	20
H5415	070	0	1	04	01	H5415_070_0	3	5		01	15;		2		2			2		1	20	50
H5415	070	0	1	04	01	H5415_070_0	3	6		01	11a;		2		2			2		1	24	24
H5415	070	0	1	04	01	H5415_070_0	3	7		01	8a1;		2		1	40.00	40.00	2		1	40	50
H5415	070	0	1	04	01	H5415_070_0	3	8		11	5;6;9a;9b;11b;11c;	13c;14c;	2		2			2		1	50	50
H5415	070	0	1	04	01	H5415_070_0	3	9		10		13b;	1	10.00	2			2		1	50	50
H5415	801	0	1	04	01	H5415_801_0	1	1		01	6;14a;		2		2			2		1	0	0
H5415	801	0	1	04	01	H5415_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5415	803	0	1	04	01	H5415_803_0	1	1		01	6;14a;		2		2			2		1	0	0
H5415	803	0	1	04	01	H5415_803_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5415	804	0	1	04	01	H5415_804_0	1	1		01	6;14a;		2		2			2		1	0	0
H5415	804	0	1	04	01	H5415_804_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5415	806	0	2	04	01	H5415_806_0	1	1		01	6;14a;		2		2			2		1	0	0
H5415	806	0	2	04	01	H5415_806_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5415	807	0	2	04	01	H5415_807_0	1	1		01	6;14a;		2		2			2		1	0	0
H5415	807	0	2	04	01	H5415_807_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5415	808	0	2	04	01	H5415_808_0	1	1		01	6;14a;		2		2			2		1	0	0
H5415	808	0	2	04	01	H5415_808_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5434	002	0	1	04	01	H5434_002_0	6	1	40%	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11b;14a;14d;14e;16b;17a;17b;18a;	9d;	2		2			2		1	40	40
H5434	002	0	1	04	01	H5434_002_0	6	2	50% DME & Part B Drugs	01	6;11a;15;		2		2			2		1	50	50
H5434	002	0	1	04	01	H5434_002_0	6	3	Ambulance	01	10a;		2		1	150.00	150.00	2		2		
H5434	002	0	1	04	01	H5434_002_0	6	4	20%	01	11c;12;		2		2			2		1	20	20
H5434	002	0	1	04	01	H5434_002_0	6	5	Fitness	10		14c;	2		2			2		2		
H5434	002	0	1	04	01	H5434_002_0	6	6	Dental - 50%	10		16a;16b;	2		2			2		1	50	50
H5434	002	0	1	04	01	H5434_002_0	6	8	Routine Eye Exam	10		17a;	2		2			2		1	100	100
H5434	002	0	1	04	01	H5434_002_0	6	7	Eyewear	10		17b;	2		2			2		1	100	100
H5434	801	0	1	04	01	H5434_801_0	2	1		01	6;14a;		2		2			2		1	0	0
H5434	801	0	1	04	01	H5434_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5434	802	0	1	04	01	H5434_802_0	2	1		01	6;14a;		2		2			2		1	0	0
H5434	802	0	1	04	01	H5434_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5439	005	0	1	04	01	H5439_005_0	4	1	Group 1 - $35	01	7a;		2		1	35.00	35.00	2		2		
H5439	005	0	1	04	01	H5439_005_0	4	9	Group 9 - 20%	01	12;		2		2			2		1	20	20
H5439	005	0	1	04	01	H5439_005_0	4	8	Group 8 - 10%	11	11a;11b;15;	14b;	2		2			2		1	10	10
H5439	005	0	1	04	01	H5439_005_0	4	7	Group 7 - 10% or 20%	01	11c;		2		2			2		1	10	20
H5439	005	0	1	04	01	H5439_005_0	4	6	Group 6 - 30%	11	8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;18a;	9d;	2		2			2		1	30	30
H5439	005	0	1	04	01	H5439_005_0	4	5	Group 5 - 0% or 30%	11	17a;	17a;	2		2			2		1	0	30
H5439	005	0	1	04	01	H5439_005_0	4	4	Group 4 - $0	11	6;14a;14d;14e;16b;17b;	14c;	2		1	0.00	0.00	2		2		
H5439	005	0	1	04	01	H5439_005_0	4	3	Group 3 - $40	01	3-1;3-2;3-3;5;7b;7c;7d;7e;7f;7h;7i;		2		1	40.00	40.00	2		2		
H5439	005	0	1	04	01	H5439_005_0	4	2	Group 2 - $345	01	10a;		2		1	345.00	345.00	2		2		
H5439	005	0	1	04	01	H5439_005_0	4	10	Group 10 - $35 or $40	01	7g;		2		1	35.00	40.00	2		2		
H5439	007	0	1	04	01	H5439_007_0	5	1	Group 1 - $30	01	7a;		2		1	30.00	30.00	2		2		
H5439	007	0	1	04	01	H5439_007_0	5	10	Group 10 - $30 or $40	01	7g;		2		1	30.00	40.00	2		2		
H5439	007	0	1	04	01	H5439_007_0	5	6	Group 6 - 30%	11	8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;18a;	9d;	2		2			2		1	30	30
H5439	007	0	1	04	01	H5439_007_0	5	7	Group 7 - 10% or 20%	01	11c;		2		2			2		1	10	20
H5439	007	0	1	04	01	H5439_007_0	5	8	Group 8 - 10%	11	11a;11b;15;	14b;	2		2			2		1	10	10
H5439	007	0	1	04	01	H5439_007_0	5	9	Group 9 - 20%	01	12;		2		2			2		1	20	20
H5439	007	0	1	04	01	H5439_007_0	5	5	Group 5 - 0% or 30%	11	17a;	17a;	2		2			2		1	0	30
H5439	007	0	1	04	01	H5439_007_0	5	2	Group 2 - $315	01	10a;		2		1	315.00	315.00	2		2		
H5439	007	0	1	04	01	H5439_007_0	5	3	Group 3 - $40	01	3-1;3-2;3-3;5;7b;7c;7d;7e;7f;7h;7i;		2		1	40.00	40.00	2		2		
H5439	007	0	1	04	01	H5439_007_0	5	4	Group 4 - $0	11	6;14a;14d;14e;16b;17b;	14c;	2		1	0.00	0.00	2		2		
H5439	801	0	1	04	01	H5439_801_0	3	1		01	6;14a;		2		2			2		1	0	0
H5439	801	0	1	04	01	H5439_801_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5439	802	0	1	04	01	H5439_802_0	3	1		01	6;14a;		2		2			2		1	0	0
H5439	802	0	1	04	01	H5439_802_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5439	803	0	1	04	01	H5439_803_0	3	1		01	6;14a;		2		2			2		1	0	0
H5439	803	0	1	04	01	H5439_803_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5508	001	0	1	04	01	H5508_001_0	7	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;12;14a;14d;14e;15;16b;17a;17b;18a;	17a;17b;	2		2			2		1	30	30
H5508	001	0	1	04	01	H5508_001_0	7	2	Group 2	10		14c;	1	150.00	2			2		2		
H5508	001	0	1	04	01	H5508_001_0	7	3	Group 3	10		16a;	2		2			2		1	50	50
H5508	001	0	1	04	01	H5508_001_0	7	4	Group 4	01	11a;11b;11c;		2		2			2		1	25	25
H5508	002	0	1	04	01	H5508_002_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;12;14a;14d;14e;15;16b;17a;17b;18a;	17a;17b;	2		2			2		1	30	30
H5508	002	0	1	04	01	H5508_002_0	4	2	Group 2	10		14c;	1	150.00	2			2		2		
H5508	002	0	1	04	01	H5508_002_0	4	4	Group 4	01	11a;11b;11c;		2		2			2		1	25	25
H5508	002	0	1	04	01	H5508_002_0	4	3	Group 3	10		16a;	2		2			2		1	50	50
H5508	005	0	1	04	01	H5508_005_0	7	2	Group 2	10		14c;	1	150.00	2			2		2		
H5508	005	0	1	04	01	H5508_005_0	7	1	group 1	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;12;14a;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	30	30
H5508	005	0	1	04	01	H5508_005_0	7	3	Group 3	01	11a;11b;11c;		2		2			2		1	25	25
H5508	006	0	1	04	01	H5508_006_0	5	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;12;14a;14d;14e;15;16b;17a;17b;18a;	17a;17b;	2		2			2		1	30	30
H5508	006	0	1	04	01	H5508_006_0	5	4	Group 4	01	11a;11b;11c;		2		2			2		1	25	25
H5508	006	0	1	04	01	H5508_006_0	5	3	Group 3	10		16a;	2		2			2		1	50	50
H5508	006	0	1	04	01	H5508_006_0	5	2	Group 2	10		14c;	1	150.00	2			2		2		
H5508	801	0	1	04	01	H5508_801_0	2	1		01	6;14a;		2		2			2		2		
H5508	801	0	1	04	01	H5508_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5508	802	0	1	04	01	H5508_802_0	1	1	Group 1	01	6;14a;		2		2			2		2		
H5508	802	0	1	04	01	H5508_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5508	803	0	1	04	01	H5508_803_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5508	803	0	1	04	01	H5508_803_0	1	1		01	6;14a;		2		2			2		2		
H5508	804	0	1	04	01	H5508_804_0	1	1		01	6;14a;		2		2			2		2		
H5508	804	0	1	04	01	H5508_804_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5520	001	0	1	04	01	H5520_001_0	2	1	Group $20	01	7a;8b3;		2		1	20.00	20.00	2		2		
H5520	001	0	1	04	01	H5520_001_0	2	8	Group $15	01	6;7b;		2		1	15.00	15.00	2		2		
H5520	001	0	1	04	01	H5520_001_0	2	7	Group $100	01	10a;		2		1	100.00	100.00	2		2		
H5520	001	0	1	04	01	H5520_001_0	2	6	Group $0 or 20%	01	11c;		2		1	0.00	0.00	2		1	20	20
H5520	001	0	1	04	01	H5520_001_0	2	5	Group $0 - $40	11	17a;	17a;	2		1	0.00	40.00	2		2		
H5520	001	0	1	04	01	H5520_001_0	2	4	Group 20%	01	8b1;8b2;11a;11b;12;15;		2		2			2		1	20	20
H5520	001	0	1	04	01	H5520_001_0	2	3	Group $50	01	7e;7h;9c;		2		1	50.00	50.00	2		2		
H5520	001	0	1	04	01	H5520_001_0	2	2	Group $35	01	3-1;3-2;3-3;7c;7i;		2		1	35.00	35.00	2		2		
H5520	001	0	1	04	01	H5520_001_0	2	15	Group $20 - $40	01	7g;		2		1	20.00	40.00	2		2		
H5520	001	0	1	04	01	H5520_001_0	2	14	Group $40	01	7d;7f;16b;18a;		2		1	40.00	40.00	2		2		
H5520	001	0	1	04	01	H5520_001_0	2	13	Group $0 - $15 with $500 Ben Max	10		7b;13a;14c;	1	500.00	1	0.00	15.00	2		2		
H5520	001	0	1	04	01	H5520_001_0	2	12	Group 0% - 20%	01	8a1;		2		2			2		1	0	20
H5520	001	0	1	04	01	H5520_001_0	2	11	Group $0	11	5;8a2;9d;14a;14d;14e;17b;	9d;14b;17b;	2		1	0.00	0.00	2		2		
H5520	001	0	1	04	01	H5520_001_0	2	10	Group $175	01	9b;		2		1	175.00	175.00	2		2		
H5520	001	0	1	04	01	H5520_001_0	2	9	Group $200	01	9a;		2		1	200.00	200.00	2		2		
H5520	002	0	1	04	01	H5520_002_0	3	1	Group $20 - $40	01	7a;7d;7f;7g;8a2;8b3;16b;18a;		2		1	20.00	40.00	2		2		
H5520	002	0	1	04	01	H5520_002_0	3	10	Group $0	11	5;9d;14a;14d;14e;17b;	9d;14b;17b;	2		1	0.00	0.00	2		2		
H5520	002	0	1	04	01	H5520_002_0	3	11	Group 0% - 19%	01	8a1;		2		2			2		1	0	19
H5520	002	0	1	04	01	H5520_002_0	3	12	Group $0 or 19%	01	11c;		2		1	0.00	0.00	2		1	19	19
H5520	002	0	1	04	01	H5520_002_0	3	13	Group $295	01	10a;		2		1	295.00	295.00	2		2		
H5520	002	0	1	04	01	H5520_002_0	3	14	Group - $50	01	7e;7h;9c;		2		1	50.00	50.00	2		2		
H5520	002	0	1	04	01	H5520_002_0	3	9	Group $250	01	9a;		2		1	250.00	250.00	2		2		
H5520	002	0	1	04	01	H5520_002_0	3	3	Group $0 - $15 with $500 Ben Max	10		7b;13a;14c;	1	500.00	1	0.00	15.00	2		2		
H5520	002	0	1	04	01	H5520_002_0	3	4	Group 19%	01	8b1;8b2;11a;11b;15;		2		2			2		1	19	19
H5520	002	0	1	04	01	H5520_002_0	3	5	Group 20%	01	12;		2		2			2		1	20	20
H5520	002	0	1	04	01	H5520_002_0	3	6	Group $0 - $40	11	17a;	17a;	2		1	0.00	40.00	2		2		
H5520	002	0	1	04	01	H5520_002_0	3	7	Group $225	01	9b;		2		1	225.00	225.00	2		2		
H5520	002	0	1	04	01	H5520_002_0	3	8	Group $15	01	6;7b;		2		1	15.00	15.00	2		2		
H5520	002	0	1	04	01	H5520_002_0	3	2	Group $35	01	3-1;3-2;3-3;7c;7i;		2		1	35.00	35.00	2		2		
H5520	003	0	1	04	01	H5520_003_0	2	8	Group $15	01	6;7b;		2		1	15.00	15.00	2		2		
H5520	003	0	1	04	01	H5520_003_0	2	9	Group $200	01	9a;		2		1	200.00	200.00	2		2		
H5520	003	0	1	04	01	H5520_003_0	2	7	Group $100	01	10a;		2		1	100.00	100.00	2		2		
H5520	003	0	1	04	01	H5520_003_0	2	6	Group $0 or 20%	01	11c;		2		1	0.00	0.00	2		1	20	20
H5520	003	0	1	04	01	H5520_003_0	2	5	Group $0 - $40	11	17a;	17a;	2		1	0.00	40.00	2		2		
H5520	003	0	1	04	01	H5520_003_0	2	4	Group 20%	01	8b1;8b2;11a;11b;12;15;		2		2			2		1	20	20
H5520	003	0	1	04	01	H5520_003_0	2	3	Group $50	01	7e;7h;9c;		2		1	50.00	50.00	2		2		
H5520	003	0	1	04	01	H5520_003_0	2	2	Group $35	01	3-1;3-2;3-3;7c;7i;		2		1	35.00	35.00	2		2		
H5520	003	0	1	04	01	H5520_003_0	2	15	Group $20 - $40	01	7g;		2		1	20.00	40.00	2		2		
H5520	003	0	1	04	01	H5520_003_0	2	14	Group $40	01	7d;7f;16b;18a;		2		1	40.00	40.00	2		2		
H5520	003	0	1	04	01	H5520_003_0	2	13	Group $0 - $15 with $500 Ben Max	10		7b;13a;14c;	1	500.00	1	0.00	15.00	2		2		
H5520	003	0	1	04	01	H5520_003_0	2	12	Group 0% - 20%	01	8a1;		2		2			2		1	0	20
H5520	003	0	1	04	01	H5520_003_0	2	11	Group $0	11	5;8a2;9d;14a;14d;14e;17b;	9d;14b;17b;	2		1	0.00	0.00	2		2		
H5520	003	0	1	04	01	H5520_003_0	2	10	Group $175	01	9b;		2		1	175.00	175.00	2		2		
H5520	003	0	1	04	01	H5520_003_0	2	1	Group $20	01	7a;8b3;		2		1	20.00	20.00	2		2		
H5520	004	0	1	04	01	H5520_004_0	6	1	Group $20 - $40	01	7a;7d;7f;7g;8a2;8b3;16b;18a;		2		1	20.00	40.00	2		2		
H5520	004	0	1	04	01	H5520_004_0	6	10	Group $0	11	5;9d;14a;14d;14e;17b;	9d;14b;17b;	2		1	0.00	0.00	2		2		
H5520	004	0	1	04	01	H5520_004_0	6	11	Group 0% - 19%	01	8a1;		2		2			2		1	0	19
H5520	004	0	1	04	01	H5520_004_0	6	12	Group $0 or 19%	01	11c;		2		1	0.00	0.00	2		1	19	19
H5520	004	0	1	04	01	H5520_004_0	6	13	Group $200	01	10a;		2		1	200.00	200.00	2		2		
H5520	004	0	1	04	01	H5520_004_0	6	14	Group $50	01	7e;7h;9c;		2		1	50.00	50.00	2		2		
H5520	004	0	1	04	01	H5520_004_0	6	9	Group $250	01	9a;		2		1	250.00	250.00	2		2		
H5520	004	0	1	04	01	H5520_004_0	6	3	Group $0 - $15 with $500 Ben Max	10		7b;13a;14c;	1	500.00	1	0.00	15.00	2		2		
H5520	004	0	1	04	01	H5520_004_0	6	4	Group 19%	01	8b1;8b2;11a;11b;15;		2		2			2		1	19	19
H5520	004	0	1	04	01	H5520_004_0	6	5	Group 20%	01	12;		2		2			2		1	20	20
H5520	004	0	1	04	01	H5520_004_0	6	6	Group $0 - $40	11	17a;	17a;	2		1	0.00	40.00	2		2		
H5520	004	0	1	04	01	H5520_004_0	6	7	Group $225	01	9b;		2		1	225.00	225.00	2		2		
H5520	004	0	1	04	01	H5520_004_0	6	8	Group $15	01	6;7b;		2		1	15.00	15.00	2		2		
H5520	004	0	1	04	01	H5520_004_0	6	2	Group $35	01	3-1;3-2;3-3;7c;7i;		2		1	35.00	35.00	2		2		
H5520	012	1	1	04	01	H5520_012_1	3	1	Group $20	01	7b;8a2;8b3;		2		1	20.00	20.00	2		2		
H5520	012	1	1	04	01	H5520_012_1	3	10	Group $15	01	6;		2		1	15.00	15.00	2		2		
H5520	012	1	1	04	01	H5520_012_1	3	11	Group $30 - $50	01	7g;		2		1	30.00	50.00	2		2		
H5520	012	1	1	04	01	H5520_012_1	3	12	Group $30	01	7a;		2		1	30.00	30.00	2		2		
H5520	012	1	1	04	01	H5520_012_1	3	2	Group $35	01	3-1;3-2;3-3;7c;7i;		2		1	35.00	35.00	2		2		
H5520	012	1	1	04	01	H5520_012_1	3	9	Group 0% - 20%	01	8a1;		2		2			2		1	0	20
H5520	012	1	1	04	01	H5520_012_1	3	4	Group 20%	01	8b1;8b2;9a;9b;11a;11b;12;15;17b;		2		2			2		1	20	20
H5520	012	1	1	04	01	H5520_012_1	3	5	Group $0 or 20%	01	11c;		2		1	0.00	0.00	2		1	20	20
H5520	012	1	1	04	01	H5520_012_1	3	6	Group $380	01	10a;		2		1	380.00	380.00	2		2		
H5520	012	1	1	04	01	H5520_012_1	3	7	Group $0	11	5;9d;14a;14d;14e;	9d;14b;14c;	2		1	0.00	0.00	2		2		
H5520	012	1	1	04	01	H5520_012_1	3	8	Group $0 - $50	01	17a;		2		1	0.00	50.00	2		2		
H5520	012	1	1	04	01	H5520_012_1	3	3	Group $50	01	7d;7e;7f;7h;9c;16b;18a;		2		1	50.00	50.00	2		2		
H5520	012	2	1	04	01	H5520_012_2	3	1	Group $20	01	7b;		2		1	20.00	20.00	2		2		
H5520	012	2	1	04	01	H5520_012_2	3	10	Group $0	11	5;9d;14a;14d;14e;	9d;14b;14c;	2		1	0.00	0.00	2		2		
H5520	012	2	1	04	01	H5520_012_2	3	11	Group $30 - $50	01	7g;		2		1	30.00	50.00	2		2		
H5520	012	2	1	04	01	H5520_012_2	3	12	Group $15	01	6;		2		1	15.00	15.00	2		2		
H5520	012	2	1	04	01	H5520_012_2	3	13	Group $30	01	7a;		2		1	30.00	30.00	2		2		
H5520	012	2	1	04	01	H5520_012_2	3	14	Group 30%	01	8b1;8b2;9a;9b;11a;11b;12;15;		2		2			2		1	30	30
H5520	012	2	1	04	01	H5520_012_2	3	2	Group $35	01	3-1;3-2;3-3;7c;7i;		2		1	35.00	35.00	2		2		
H5520	012	2	1	04	01	H5520_012_2	3	3	Group $50	01	7d;7e;7f;7h;9c;16b;18a;		2		1	50.00	50.00	2		2		
H5520	012	2	1	04	01	H5520_012_2	3	4	Group 20%	01	17b;		2		2			2		1	20	20
H5520	012	2	1	04	01	H5520_012_2	3	5	Group $0 or 20%	01	11c;		2		1	0.00	0.00	2		1	20	20
H5520	012	2	1	04	01	H5520_012_2	3	6	Group $325	01	10a;		2		1	325.00	325.00	2		2		
H5520	012	2	1	04	01	H5520_012_2	3	7	Group $25	01	8a2;8b3;		2		1	25.00	25.00	2		2		
H5520	012	2	1	04	01	H5520_012_2	3	8	Group $0 - $50	01	17a;		2		1	0.00	50.00	2		2		
H5520	012	2	1	04	01	H5520_012_2	3	9	Group 0% - 20%	01	8a1;		2		2			2		1	0	20
H5520	012	3	1	04	01	H5520_012_3	4	14	Group $325	01	9a;		2		1	325.00	325.00	2		2		
H5520	012	3	1	04	01	H5520_012_3	4	13	Group $15	01	6;		2		1	15.00	15.00	2		2		
H5520	012	3	1	04	01	H5520_012_3	4	12	Group $30 - $50	01	7g;		2		1	30.00	50.00	2		2		
H5520	012	3	1	04	01	H5520_012_3	4	11	Group $30	01	7a;		2		1	30.00	30.00	2		2		
H5520	012	3	1	04	01	H5520_012_3	4	10	Group $275	01	9b;		2		1	275.00	275.00	2		2		
H5520	012	3	1	04	01	H5520_012_3	4	1	Group $20	01	7b;8a2;8b3;		2		1	20.00	20.00	2		2		
H5520	012	3	1	04	01	H5520_012_3	4	9	Group 0% - 20%	01	8a1;		2		2			2		1	0	20
H5520	012	3	1	04	01	H5520_012_3	4	3	Group $50	01	7d;7e;7f;7h;9c;16b;18a;		2		1	50.00	50.00	2		2		
H5520	012	3	1	04	01	H5520_012_3	4	4	Group 20%	01	8b1;8b2;11a;11b;12;15;17b;		2		2			2		1	20	20
H5520	012	3	1	04	01	H5520_012_3	4	5	Group $0 or 20%	01	11c;		2		1	0.00	0.00	2		1	20	20
H5520	012	3	1	04	01	H5520_012_3	4	6	Group $375	01	10a;		2		1	375.00	375.00	2		2		
H5520	012	3	1	04	01	H5520_012_3	4	7	Group $0	11	5;9d;14a;14d;14e;	9d;14b;14c;	2		1	0.00	0.00	2		2		
H5520	012	3	1	04	01	H5520_012_3	4	8	Group $0 - $50	01	17a;		2		1	0.00	50.00	2		2		
H5520	012	3	1	04	01	H5520_012_3	4	2	Group $35	01	3-1;3-2;3-3;7c;7i;		2		1	35.00	35.00	2		2		
H5520	012	4	1	04	01	H5520_012_4	3	14	Group $325	01	9a;		2		1	325.00	325.00	2		2		
H5520	012	4	1	04	01	H5520_012_4	3	13	Group $275	01	9b;		2		1	275.00	275.00	2		2		
H5520	012	4	1	04	01	H5520_012_4	3	12	Group $30	01	7a;		2		1	30.00	30.00	2		2		
H5520	012	4	1	04	01	H5520_012_4	3	11	Group $30 - $50	01	7g;		2		1	30.00	50.00	2		2		
H5520	012	4	1	04	01	H5520_012_4	3	10	Group $15	01	6;		2		1	15.00	15.00	2		2		
H5520	012	4	1	04	01	H5520_012_4	3	1	Group $20	01	7b;8a2;8b3;		2		1	20.00	20.00	2		2		
H5520	012	4	1	04	01	H5520_012_4	3	2	Group $35	01	3-1;3-2;3-3;7c;7i;		2		1	35.00	35.00	2		2		
H5520	012	4	1	04	01	H5520_012_4	3	9	Group 0% - 20%	01	8a1;		2		2			2		1	0	20
H5520	012	4	1	04	01	H5520_012_4	3	8	Group $0 - $50	01	17a;		2		1	0.00	50.00	2		2		
H5520	012	4	1	04	01	H5520_012_4	3	7	Group $0	11	5;9d;14a;14d;14e;	9d;14b;14c;	2		1	0.00	0.00	2		2		
H5520	012	4	1	04	01	H5520_012_4	3	6	Group $380	01	10a;		2		1	380.00	380.00	2		2		
H5520	012	4	1	04	01	H5520_012_4	3	5	Group $0 or 20%	01	11c;		2		1	0.00	0.00	2		1	20	20
H5520	012	4	1	04	01	H5520_012_4	3	4	Group 20%	01	8b1;8b2;11a;11b;12;15;17b;		2		2			2		1	20	20
H5520	012	4	1	04	01	H5520_012_4	3	3	Group $50	01	7d;7e;7f;7h;9c;16b;18a;		2		1	50.00	50.00	2		2		
H5520	014	0	1	04	01	H5520_014_0	5	1	Group $20	01	7b;8a2;8b3;		2		1	20.00	20.00	2		2		
H5520	014	0	1	04	01	H5520_014_0	5	10	Group $30	01	7a;		2		1	30.00	30.00	2		2		
H5520	014	0	1	04	01	H5520_014_0	5	11	Group $30 - $50	01	7g;		2		1	30.00	50.00	2		2		
H5520	014	0	1	04	01	H5520_014_0	5	12	Group $15	01	6;		2		1	15.00	15.00	2		2		
H5520	014	0	1	04	01	H5520_014_0	5	13	Group $285	01	9b;		2		1	285.00	285.00	2		2		
H5520	014	0	1	04	01	H5520_014_0	5	14	Group $335	01	9a;		2		1	335.00	335.00	2		2		
H5520	014	0	1	04	01	H5520_014_0	5	9	Group 0% - 20%	01	8a1;		2		2			2		1	0	20
H5520	014	0	1	04	01	H5520_014_0	5	7	Group $0	11	5;9d;14a;14d;14e;	9d;14b;14c;	2		1	0.00	0.00	2		2		
H5520	014	0	1	04	01	H5520_014_0	5	6	Group $380	01	10a;		2		1	380.00	380.00	2		2		
H5520	014	0	1	04	01	H5520_014_0	5	5	Group $0 or 20%	01	11c;		2		1	0.00	0.00	2		1	20	20
H5520	014	0	1	04	01	H5520_014_0	5	4	Group 20%	01	8b1;8b2;11a;11b;12;15;17b;		2		2			2		1	20	20
H5520	014	0	1	04	01	H5520_014_0	5	3	Group $50	01	7d;7e;7f;7h;9c;16b;18a;		2		1	50.00	50.00	2		2		
H5520	014	0	1	04	01	H5520_014_0	5	2	Group $35	01	3-1;3-2;3-3;7c;7i;		2		1	35.00	35.00	2		2		
H5520	014	0	1	04	01	H5520_014_0	5	8	Group $0 - $50	01	17a;		2		1	0.00	50.00	2		2		
H5520	015	1	1	04	01	H5520_015_1	5	11	Group $15	01	6;		2		1	15.00	15.00	2		2		
H5520	015	1	1	04	01	H5520_015_1	5	12	Group $30	01	7a;		2		1	30.00	30.00	2		2		
H5520	015	1	1	04	01	H5520_015_1	5	13	Group $30 - $50	01	7g;		2		1	30.00	50.00	2		2		
H5520	015	1	1	04	01	H5520_015_1	5	14	Group $325	01	9a;		2		1	325.00	325.00	2		2		
H5520	015	1	1	04	01	H5520_015_1	5	2	Group $35	01	3-1;3-2;3-3;7c;7i;		2		1	35.00	35.00	2		2		
H5520	015	1	1	04	01	H5520_015_1	5	3	Group $50	01	7d;7e;7f;7h;9c;16b;18a;		2		1	50.00	50.00	2		2		
H5520	015	1	1	04	01	H5520_015_1	5	4	Group 20%	01	8b1;8b2;11a;11b;12;15;		2		2			2		1	20	20
H5520	015	1	1	04	01	H5520_015_1	5	5	Group $0 or 20%	01	11c;		2		1	0.00	0.00	2		1	20	20
H5520	015	1	1	04	01	H5520_015_1	5	6	Group $250	01	10a;		2		1	250.00	250.00	2		2		
H5520	015	1	1	04	01	H5520_015_1	5	7	Group $0	11	5;9d;14a;14d;14e;17b;	9d;14b;14c;17b;	2		1	0.00	0.00	2		2		
H5520	015	1	1	04	01	H5520_015_1	5	8	Group $0 - $50	11	17a;	17a;	2		1	0.00	50.00	2		2		
H5520	015	1	1	04	01	H5520_015_1	5	9	Group 0% - 20%	01	8a1;		2		2			2		1	0	20
H5520	015	1	1	04	01	H5520_015_1	5	1	Group $20	01	7b;8a2;8b3;		2		1	20.00	20.00	2		2		
H5520	015	1	1	04	01	H5520_015_1	5	10	Group $275	01	9b;		2		1	275.00	275.00	2		2		
H5520	015	2	1	04	01	H5520_015_2	5	1	Group $20	01	7b;8a2;8b3;		2		1	20.00	20.00	2		2		
H5520	015	2	1	04	01	H5520_015_2	5	10	Group $275	01	9b;		2		1	275.00	275.00	2		2		
H5520	015	2	1	04	01	H5520_015_2	5	9	Group 0% - 20%	01	8a1;		2		2			2		1	0	20
H5520	015	2	1	04	01	H5520_015_2	5	8	Group $0 - $50	11	17a;	17a;	2		1	0.00	50.00	2		2		
H5520	015	2	1	04	01	H5520_015_2	5	7	Group $0	11	5;9d;14a;14d;14e;17b;	9d;14b;14c;17b;	2		1	0.00	0.00	2		2		
H5520	015	2	1	04	01	H5520_015_2	5	6	Group $395	01	10a;		2		1	395.00	395.00	2		2		
H5520	015	2	1	04	01	H5520_015_2	5	5	Group $0 or 20%	01	11c;		2		1	0.00	0.00	2		1	20	20
H5520	015	2	1	04	01	H5520_015_2	5	11	Group $15	01	6;		2		1	15.00	15.00	2		2		
H5520	015	2	1	04	01	H5520_015_2	5	12	Group $30	01	7a;		2		1	30.00	30.00	2		2		
H5520	015	2	1	04	01	H5520_015_2	5	13	Group $30 - $50	01	7g;		2		1	30.00	50.00	2		2		
H5520	015	2	1	04	01	H5520_015_2	5	14	Group $325	01	9a;		2		1	325.00	325.00	2		2		
H5520	015	2	1	04	01	H5520_015_2	5	2	Group $35	01	3-1;3-2;3-3;7c;7i;		2		1	35.00	35.00	2		2		
H5520	015	2	1	04	01	H5520_015_2	5	3	Group $50	01	7d;7e;7f;7h;9c;16b;18a;		2		1	50.00	50.00	2		2		
H5520	015	2	1	04	01	H5520_015_2	5	4	Group 20%	01	8b1;8b2;11a;11b;12;15;		2		2			2		1	20	20
H5520	807	0	1	04	01	H5520_807_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5520	807	0	1	04	01	H5520_807_0	2	1		01	6;14a;		2		2			2		1	0	0
H5520	808	0	1	04	01	H5520_808_0	2	1		01	6;14a;		2		2			2		1	0	0
H5520	808	0	1	04	01	H5520_808_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5520	809	0	1	04	01	H5520_809_0	2	1		01	6;14a;		2		2			2		1	0	0
H5520	809	0	1	04	01	H5520_809_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5521	012	0	1	04	01	H5521_012_0	10	1	25%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	25	25
H5521	012	0	1	04	01	H5521_012_0	10	2	$300	01	10a;		2		1	300.00	300.00	2		2		
H5521	012	0	1	04	01	H5521_012_0	10	3	20%	01	12;		2		2			2		1	20	20
H5521	012	0	1	04	01	H5521_012_0	10	4	$0- $75	10		14c;	2		1	0.00	75.00	2		2		
H5521	012	0	1	04	01	H5521_012_0	10	5	Preventive Dental	10		16a;	2		2			1	75.00	1	30	30
H5521	012	0	1	04	01	H5521_012_0	10	6	Eyewear	10		17b;	2		1	0.00	0.00	2		2		
H5521	012	0	1	04	01	H5521_012_0	10	7	Hearing Aids	10		18b;	2		1	0.00	0.00	2		2		
H5521	012	0	1	04	01	H5521_012_0	10	8	0%-25%	01	14a;		2		2			2		1	0	25
H5521	013	0	1	04	01	H5521_013_0	4	3	20% Tier	01	12;14d;		2		2			2		1	20	20
H5521	013	0	1	04	01	H5521_013_0	4	2	Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H5521	013	0	1	04	01	H5521_013_0	4	1	30% Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	30	30
H5521	013	0	1	04	01	H5521_013_0	4	4	14C 0 and $75 for OON Fitness	10		14c;	2		1	0.00	75.00	2		2		
H5521	013	0	1	04	01	H5521_013_0	4	6	Immunization	01	14a;		2		2			2		1	0	30
H5521	013	0	1	04	01	H5521_013_0	4	5	Dental Allowance	10		16a;	2		2			2		2		
H5521	015	0	1	04	01	H5521_015_0	7	1	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	50	50
H5521	015	0	1	04	01	H5521_015_0	7	2	$350	01	10a;		2		1	350.00	350.00	2		2		
H5521	015	0	1	04	01	H5521_015_0	7	3	20%	01	12;14d;		2		2			2		1	20	20
H5521	015	0	1	04	01	H5521_015_0	7	4	$0 - $75	10		14c;	2		1	0.00	75.00	2		2		
H5521	015	0	1	04	01	H5521_015_0	7	5	0%-50%	01	14a;		2		2			2		1	0	50
H5521	016	0	1	04	01	H5521_016_0	5	1	30%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	30	30
H5521	016	0	1	04	01	H5521_016_0	5	2	$250	01	10a;		2		1	250.00	250.00	2		2		
H5521	016	0	1	04	01	H5521_016_0	5	4	14c	10		14c;	2		1	0.00	75.00	2		1	30	30
H5521	016	0	1	04	01	H5521_016_0	5	3	20%	01	12;		2		2			2		1	20	20
H5521	016	0	1	04	01	H5521_016_0	5	5	0-30%	01	14a;		2		2			2		1	0	30
H5521	020	0	1	04	01	H5521_020_0	6	3	ESRD and Kidney Disease Education	01	12;14d;		2		2			2		1	20	20
H5521	020	0	1	04	01	H5521_020_0	6	2	Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H5521	020	0	1	04	01	H5521_020_0	6	1	25% Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	25	25
H5521	020	0	1	04	01	H5521_020_0	6	4	$0 Group	10		16a;	2		1	0.00	0.00	2		2		
H5521	020	0	1	04	01	H5521_020_0	6	6	14c Supplemental Benefits	10		14c;	2		1	0.00	75.00	2		2		
H5521	020	0	1	04	01	H5521_020_0	6	5	Medicare-covered Preventive Services	01	14a;		2		2			2		1	0	25
H5521	022	0	1	04	01	H5521_022_0	8	1	40% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	40	40
H5521	022	0	1	04	01	H5521_022_0	8	5	Extra Benefits Range	10		14c;	2		1	0.00	75.00	2		2		
H5521	022	0	1	04	01	H5521_022_0	8	4	OON Range	01	14a;		2		2			2		1	0	40
H5521	022	0	1	04	01	H5521_022_0	8	3	$0 copay	10		16a;16b;17b;18b;	2		1	0.00	0.00	2		2		
H5521	022	0	1	04	01	H5521_022_0	8	2	$275 copay	01	10a;		2		1	275.00	275.00	2		2		
H5521	027	0	1	04	01	H5521_027_0	6	6	25%-50%	01	11b;		2		2			2		1	25	50
H5521	027	0	1	04	01	H5521_027_0	6	5	25%	01	11a;		2		2			2		1	25	25
H5521	027	0	1	04	01	H5521_027_0	6	4	$0-$75	10		14c;	2		1	0.00	75.00	2		2		
H5521	027	0	1	04	01	H5521_027_0	6	3	20%	01	12;14d;		2		2			2		1	20	20
H5521	027	0	1	04	01	H5521_027_0	6	2	$375	01	10a;		2		1	375.00	375.00	2		2		
H5521	027	0	1	04	01	H5521_027_0	6	7	0%-50%	01	14a;		2		2			2		1	0	50
H5521	027	0	1	04	01	H5521_027_0	6	1	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	50	50
H5521	033	0	1	04	01	H5521_033_0	7	1	Group 1	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;	2		2			2		1	30	30
H5521	033	0	1	04	01	H5521_033_0	7	8		01	10a;		2		1	300.00	300.00	2		2		
H5521	033	0	1	04	01	H5521_033_0	7	7		10		17b;18b;	2		1	0.00	0.00	2		2		
H5521	033	0	1	04	01	H5521_033_0	7	6		10		14c;	2		1	0.00	75.00	2		2		
H5521	033	0	1	04	01	H5521_033_0	7	5		01	7a;7d;7g;		2		1	75.00	75.00	2		2		
H5521	033	0	1	04	01	H5521_033_0	7	4		01	14a;		2		1	0.00	0.00	2		2		
H5521	033	0	1	04	01	H5521_033_0	7	2		01	12;		2		2			2		1	20	20
H5521	033	0	1	04	01	H5521_033_0	7	3		10		16a;16b;	2		2			2		1	50	50
H5521	037	0	1	04	01	H5521_037_0	6	3	20% for ESRD and Kidney Disease ED	01	12;14d;		2		2			2		1	20	20
H5521	037	0	1	04	01	H5521_037_0	6	2	Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H5521	037	0	1	04	01	H5521_037_0	6	1	40% OON Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	40	40
H5521	037	0	1	04	01	H5521_037_0	6	4	14C 0 and $75 for OON Fitness	10		14c;	2		1	0.00	75.00	2		2		
H5521	037	0	1	04	01	H5521_037_0	6	5	immunizations	01	14a;		2		2			2		1	0	40
H5521	037	0	1	04	01	H5521_037_0	6	6	Hearing Aid Allowance	10		18b;	2		2			2		2		
H5521	040	0	1	04	01	H5521_040_0	4	1	40% Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	40	40
H5521	040	0	1	04	01	H5521_040_0	4	2	Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H5521	040	0	1	04	01	H5521_040_0	4	3	20% OON Group	01	12;14d;		2		2			2		1	20	20
H5521	040	0	1	04	01	H5521_040_0	4	4	$0 Copayment Group	10		17b;18b;	2		1	0.00	0.00	2		2		
H5521	040	0	1	04	01	H5521_040_0	4	5	DME and Prosthetics/Medical Supplies	01	11a;11b;		2		2			2		1	30	40
H5521	040	0	1	04	01	H5521_040_0	4	6	Medicare-covered Preventive Services	01	14a;		2		2			2		1	0	40
H5521	040	0	1	04	01	H5521_040_0	4	7	14c Supplemental Benefits	10		14c;	2		1	0.00	75.00	2		2		
H5521	052	0	1	04	01	H5521_052_0	13	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	20	20
H5521	052	0	1	04	01	H5521_052_0	13	3	Group 3	01	12;		2		2			2		1	20	20
H5521	052	0	1	04	01	H5521_052_0	13	6	Group 6	01	14a;		2		2			2		1	0	20
H5521	052	0	1	04	01	H5521_052_0	13	2	Group 2	01	10a;		2		1	100.00	100.00	2		2		
H5521	052	0	1	04	01	H5521_052_0	13	5	Group 5	10		16a;17b;18b;	2		1	0.00	0.00	2		2		
H5521	052	0	1	04	01	H5521_052_0	13	4	Group 4	10		14c;	2		1	0.00	75.00	2		1	20	20
H5521	053	0	1	04	01	H5521_053_0	6	2	$300 copay	01	10a;		2		1	300.00	300.00	2		2		
H5521	053	0	1	04	01	H5521_053_0	6	3	20% coinsurance	01	12;14d;		2		2			2		1	20	20
H5521	053	0	1	04	01	H5521_053_0	6	5	OON Range	01	14a;		2		2			2		1	0	40
H5521	053	0	1	04	01	H5521_053_0	6	4	Extra Benefits Range	10		14c;	2		1	0.00	75.00	2		2		
H5521	053	0	1	04	01	H5521_053_0	6	1	40% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	40	40
H5521	055	0	1	04	01	H5521_055_0	7	5	Extra Benefits Range	10		14c;	2		1	0.00	75.00	2		2		
H5521	055	0	1	04	01	H5521_055_0	7	4	$0 copay	10		16a;17b;18b;	2		1	0.00	0.00	2		2		
H5521	055	0	1	04	01	H5521_055_0	7	2	$325 copay	01	10a;		2		1	325.00	325.00	2		2		
H5521	055	0	1	04	01	H5521_055_0	7	1	40% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	40	40
H5521	055	0	1	04	01	H5521_055_0	7	3	OON Range	01	14a;		2		2			2		1	0	40
H5521	056	0	1	04	01	H5521_056_0	6	5	OON Range	01	14a;		2		2			2		1	0	40
H5521	056	0	1	04	01	H5521_056_0	6	4	Extra Benefits Range	10		14c;	2		1	0.00	75.00	2		2		
H5521	056	0	1	04	01	H5521_056_0	6	2	$300 copay	01	10a;		2		1	300.00	300.00	2		2		
H5521	056	0	1	04	01	H5521_056_0	6	3	$30 copay	01	12;14d;		2		1	30.00	30.00	2		2		
H5521	056	0	1	04	01	H5521_056_0	6	1	40% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	40	40
H5521	057	0	1	04	01	H5521_057_0	8	3	$0 copay	10		16a;16b;17b;18b;	2		1	0.00	0.00	2		2		
H5521	057	0	1	04	01	H5521_057_0	8	2	$275 copay	01	10a;		2		1	275.00	275.00	2		2		
H5521	057	0	1	04	01	H5521_057_0	8	1	40% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	40	40
H5521	057	0	1	04	01	H5521_057_0	8	5	Extra Benefits Range	10		14c;	2		1	0.00	75.00	2		2		
H5521	057	0	1	04	01	H5521_057_0	8	4	OON Range	01	14a;		2		2			2		1	0	40
H5521	058	0	1	04	01	H5521_058_0	4	7	14a: 0-45%	01	14a;		2		2			2		1	0	45
H5521	058	0	1	04	01	H5521_058_0	4	6	$125 Allowance	10		17b;	2		2			2		2		
H5521	058	0	1	04	01	H5521_058_0	4	5	Dental Allowance	10		16a;	2		2			2		2		
H5521	058	0	1	04	01	H5521_058_0	4	4	14C $0 Copay 14C and $75 -OON Fitness	10		14c;	2		1	0.00	75.00	2		2		
H5521	058	0	1	04	01	H5521_058_0	4	2	$350 Copayment	01	10a;		2		1	350.00	350.00	2		2		
H5521	058	0	1	04	01	H5521_058_0	4	3	20% Coinsurance	01	12;14d;		2		2			2		1	20	20
H5521	058	0	1	04	01	H5521_058_0	4	1	45 % Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	45	45
H5521	059	0	1	04	01	H5521_059_0	4	7	14a: 0-45%	01	14a;		2		2			2		1	0	45
H5521	059	0	1	04	01	H5521_059_0	4	4	14C-0$ for 14C and $75 for OON Fitness	10		14c;	2		1	0.00	75.00	2		2		
H5521	059	0	1	04	01	H5521_059_0	4	3	20% coisurance	01	12;14d;		2		2			2		1	20	20
H5521	059	0	1	04	01	H5521_059_0	4	2	$350 Copayment	01	10a;		2		1	350.00	350.00	2		2		
H5521	059	0	1	04	01	H5521_059_0	4	1	45% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	45	45
H5521	059	0	1	04	01	H5521_059_0	4	6	$125	10		17b;	2		2			2		2		
H5521	059	0	1	04	01	H5521_059_0	4	5	Dental Allowance	10		16a;	2		2			2		2		
H5521	060	0	1	04	01	H5521_060_0	5	1	45% Coisurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	45	45
H5521	060	0	1	04	01	H5521_060_0	5	2	$350 Copayment	01	10a;		2		1	350.00	350.00	2		2		
H5521	060	0	1	04	01	H5521_060_0	5	3	20% Coisurance	01	12;14d;		2		2			2		1	20	20
H5521	060	0	1	04	01	H5521_060_0	5	7	14a:0-45%	01	14a;		2		2			2		1	0	45
H5521	060	0	1	04	01	H5521_060_0	5	5	Dental Allowance	10		16a;	2		2			2		2		
H5521	060	0	1	04	01	H5521_060_0	5	6	$125 Allowance	10		17b;	2		2			2		2		
H5521	060	0	1	04	01	H5521_060_0	5	4	$0 Copayment	10		14c;	2		1	0.00	75.00	2		2		
H5521	076	0	1	04	01	H5521_076_0	4	1	40% Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	40	40
H5521	076	0	1	04	01	H5521_076_0	4	2	Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H5521	076	0	1	04	01	H5521_076_0	4	3	20% OON Group	01	12;14d;		2		2			2		1	20	20
H5521	076	0	1	04	01	H5521_076_0	4	4	$0 Copayment Group	10		17b;18b;	2		1	0.00	0.00	2		2		
H5521	076	0	1	04	01	H5521_076_0	4	5	Medicare-covered Preventive Services	01	14a;		2		2			2		1	0	40
H5521	076	0	1	04	01	H5521_076_0	4	6	14c Supplemental Benefits	10		14c;	2		1	0.00	75.00	2		2		
H5521	077	0	1	04	01	H5521_077_0	4	1	40% Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	40	40
H5521	077	0	1	04	01	H5521_077_0	4	2	Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H5521	077	0	1	04	01	H5521_077_0	4	3	20% OON Group	01	12;14d;		2		2			2		1	20	20
H5521	077	0	1	04	01	H5521_077_0	4	4	$0 Copayment Group	10		16a;17b;18b;	2		1	0.00	0.00	2		2		
H5521	077	0	1	04	01	H5521_077_0	4	5	Medicare-covered Preventive Services	01	14a;		2		2			2		1	0	40
H5521	077	0	1	04	01	H5521_077_0	4	6	14c Supplemental Benefits	10		14c;	2		1	0.00	75.00	2		2		
H5521	081	0	1	04	01	H5521_081_0	6	11	$45	01	16b;18a;		2		1	45.00	45.00	2		2		
H5521	081	0	1	04	01	H5521_081_0	6	9	$75 allowance	10		17b;	2		1	0.00	0.00	2		2		
H5521	081	0	1	04	01	H5521_081_0	6	8	$150 allowance	10		16a;	2		1	0.00	0.00	2		2		
H5521	081	0	1	04	01	H5521_081_0	6	7	$250	01	10a;		2		1	250.00	250.00	2		2		
H5521	081	0	1	04	01	H5521_081_0	6	6	$55	11	3-1;3-2;3-3;7c;7d;7e;7f;7g;7h;7i;17a;	17a;18a;	2		1	55.00	55.00	2		2		
H5521	081	0	1	04	01	H5521_081_0	6	5	$0	11	14a;14d;14e;	14b;	2		1	0.00	0.00	2		2		
H5521	081	0	1	04	01	H5521_081_0	6	4	30%/$55	01	11b;		2		1	55.00	55.00	2		1	30	30
H5521	081	0	1	04	01	H5521_081_0	6	3	30%	01	8b2;11a;		2		2			2		1	30	30
H5521	081	0	1	04	01	H5521_081_0	6	2	25%	11	8a1;8a2;8b1;8b3;9a;9b;9c;9d;	9d;	2		2			2		1	25	25
H5521	081	0	1	04	01	H5521_081_0	6	12	14c	10		14c;	2		1	0.00	75.00	2		2		
H5521	081	0	1	04	01	H5521_081_0	6	1	20%	01	5;6;7b;11c;12;15;17b;		2		2			2		1	20	20
H5521	081	0	1	04	01	H5521_081_0	6	10	$40	01	7a;		2		1	40.00	40.00	2		2		
H5521	082	0	1	04	01	H5521_082_0	5	3	20%	01	12;14d;		2		2			2		1	20	20
H5521	082	0	1	04	01	H5521_082_0	5	1	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	50	50
H5521	082	0	1	04	01	H5521_082_0	5	2	$350	01	10a;		2		1	350.00	350.00	2		2		
H5521	082	0	1	04	01	H5521_082_0	5	4	$0 - $75	10		14c;	2		1	0.00	75.00	2		2		
H5521	082	0	1	04	01	H5521_082_0	5	5	0%-50%	01	14a;		2		2			2		1	0	50
H5521	083	0	1	04	01	H5521_083_0	5	5	0%-50%	01	14a;		2		2			2		1	0	50
H5521	083	0	1	04	01	H5521_083_0	5	3	20%	01	12;14d;		2		2			2		1	20	20
H5521	083	0	1	04	01	H5521_083_0	5	4	$0 - $75	10		14c;	2		1	0.00	75.00	2		2		
H5521	083	0	1	04	01	H5521_083_0	5	1	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	50	50
H5521	083	0	1	04	01	H5521_083_0	5	2	$350	01	10a;		2		1	350.00	350.00	2		2		
H5521	084	0	1	04	01	H5521_084_0	7	5	0%-50%	01	14a;		2		2			2		1	0	50
H5521	084	0	1	04	01	H5521_084_0	7	4	$0 - $75	10		14c;	2		1	0.00	75.00	2		2		
H5521	084	0	1	04	01	H5521_084_0	7	3	20%	01	12;14d;		2		2			2		1	20	20
H5521	084	0	1	04	01	H5521_084_0	7	1	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	50	50
H5521	084	0	1	04	01	H5521_084_0	7	2	$350	01	10a;		2		1	350.00	350.00	2		2		
H5521	085	0	1	04	01	H5521_085_0	4	4	14c Supplemental Benefits	10		14c;	2		1	0.00	75.00	2		2		
H5521	085	0	1	04	01	H5521_085_0	4	2	Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H5521	085	0	1	04	01	H5521_085_0	4	5	Medicare-covered Preventive Services	01	14a;		2		2			2		1	0	50
H5521	085	0	1	04	01	H5521_085_0	4	3	ESRD and Kidney Disease Education	01	12;14d;		2		2			2		1	20	20
H5521	085	0	1	04	01	H5521_085_0	4	1	50% Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	50	50
H5521	086	0	1	04	01	H5521_086_0	7	4	$0	10		14c;	2		1	0.00	75.00	2		1	50	50
H5521	086	0	1	04	01	H5521_086_0	7	1	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	50	50
H5521	086	0	1	04	01	H5521_086_0	7	5	0-50%	01	14a;		2		2			2		1	0	50
H5521	086	0	1	04	01	H5521_086_0	7	2	$300	01	10a;		2		1	300.00	300.00	2		2		
H5521	086	0	1	04	01	H5521_086_0	7	3	20%	01	12;		2		2			2		1	20	20
H5521	087	0	1	04	01	H5521_087_0	4	4	14c Supplemental Benefits	10		14c;	2		1	0.00	75.00	2		2		
H5521	087	0	1	04	01	H5521_087_0	4	1	50% Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	50	50
H5521	087	0	1	04	01	H5521_087_0	4	5	Medicare-covered Preventive Services	01	14a;		2		2			2		1	0	50
H5521	087	0	1	04	01	H5521_087_0	4	2	Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H5521	087	0	1	04	01	H5521_087_0	4	3	ESRD and Kidney Disease Education	01	12;14d;		2		2			2		1	20	20
H5521	088	0	1	04	01	H5521_088_0	4	2	Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H5521	088	0	1	04	01	H5521_088_0	4	3	ESRD and Kidney Disease Education	01	12;14d;		2		2			2		1	20	20
H5521	088	0	1	04	01	H5521_088_0	4	5	Medicare-covered Preventive Services	01	14a;		2		2			2		1	0	50
H5521	088	0	1	04	01	H5521_088_0	4	4	14c Supplemental Benefits	10		14c;	2		1	0.00	75.00	2		2		
H5521	088	0	1	04	01	H5521_088_0	4	1	50% Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	50	50
H5521	089	0	1	04	01	H5521_089_0	4	5	Medicare-covered Preventive Services	01	14a;		2		2			2		1	0	45
H5521	089	0	1	04	01	H5521_089_0	4	4	14c Supplemental Benefits	10		14c;	2		1	0.00	75.00	2		2		
H5521	089	0	1	04	01	H5521_089_0	4	2	Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H5521	089	0	1	04	01	H5521_089_0	4	1	45% Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	45	45
H5521	089	0	1	04	01	H5521_089_0	4	3	ESRD and Kidney Disease Education	01	12;14d;		2		2			2		1	20	20
H5521	090	0	1	04	01	H5521_090_0	4	3	ESRD and Kidney Disease Education	01	12;14d;		2		2			2		1	20	20
H5521	090	0	1	04	01	H5521_090_0	4	2	Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H5521	090	0	1	04	01	H5521_090_0	4	1	45% Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	45	45
H5521	090	0	1	04	01	H5521_090_0	4	5	Medicare-covered Preventive Services	01	14a;		2		2			2		1	0	45
H5521	090	0	1	04	01	H5521_090_0	4	4	14c Supplemental Benefits	10		14c;	2		1	0.00	75.00	2		2		
H5521	091	0	1	04	01	H5521_091_0	8	5	$120 Allowance	10		16a;	2		2			2		2		
H5521	091	0	1	04	01	H5521_091_0	8	6	$100 Allowance	10		17b;	2		2			2		2		
H5521	091	0	1	04	01	H5521_091_0	8	7	35%/$45	01	11b;		2		1	45.00	45.00	2		1	35	35
H5521	091	0	1	04	01	H5521_091_0	8	4	$45	01	3-1;3-2;3-3;7a;7b;7c;7d;7e;7f;7g;7h;7i;16b;17a;18a;		2		1	45.00	45.00	2		2		
H5521	091	0	1	04	01	H5521_091_0	8	3	$300	01	10a;		2		1	300.00	300.00	2		2		
H5521	091	0	1	04	01	H5521_091_0	8	2	$0	11	14e;	14b;17a;	2		2			2		2		
H5521	091	0	1	04	01	H5521_091_0	8	10	$0-35% costshare	01	14a;		2		2			2		1	0	35
H5521	091	0	1	04	01	H5521_091_0	8	1	35%	11	5;6;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11c;15;17b;	9d;	2		2			2		1	35	35
H5521	091	0	1	04	01	H5521_091_0	8	8	20%	01	12;14d;		2		2			2		1	20	20
H5521	091	0	1	04	01	H5521_091_0	8	9	$75 Costshare Fitness	10		14c;	2		1	75.00	75.00	2		2		
H5521	092	0	1	04	01	H5521_092_0	6	1	45%	11	3-1;3-2;5;6;7b;7c;7e;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9c;9d;11a;11c;14e;15;17b;	9d;17a;18a;	2		2			2		1	45	45
H5521	092	0	1	04	01	H5521_092_0	6	10	$35 to 45% coisurance	01	11b;17a;18a;		2		1	35.00	35.00	2		1	45	45
H5521	092	0	1	04	01	H5521_092_0	6	11	$0	11	14a;	14b;	2		1	0.00	0.00	2		2		
H5521	092	0	1	04	01	H5521_092_0	6	12	$850 Allowance- Comp Dental	10		16b;	2		1	0.00	0.00	2		2		
H5521	092	0	1	04	01	H5521_092_0	6	2	$35 Copay	01	3-3;7a;7d;7f;16b;		2		1	35.00	35.00	2		2		
H5521	092	0	1	04	01	H5521_092_0	6	9	$300 Allowance	10		18b;	2		2			2		2		
H5521	092	0	1	04	01	H5521_092_0	6	4	20%	01	12;14d;		2		2			2		1	20	20
H5521	092	0	1	04	01	H5521_092_0	6	5	$350	01	10a;		2		1	350.00	350.00	2		2		
H5521	092	0	1	04	01	H5521_092_0	6	6	14C- $0-$75 copay fitness	10		14c;	2		1	0.00	75.00	2		2		
H5521	092	0	1	04	01	H5521_092_0	6	7	$150 Allowance	10		16a;	2		1	0.00	0.00	2		2		
H5521	092	0	1	04	01	H5521_092_0	6	8	$125 Allowance	10		17b;	2		2			2		2		
H5521	092	0	1	04	01	H5521_092_0	6	3	$264 Copay	01	9a;9b;		2		1	264.00	264.00	2		2		
H5521	093	0	1	04	01	H5521_093_0	7	1	45%	11	3-1;3-2;5;6;7b;7c;7e;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9c;9d;11a;11c;14e;15;17b;	9d;17a;18a;	2		2			2		1	45	45
H5521	093	0	1	04	01	H5521_093_0	7	10	$50 to 45% coisurance	01	11b;17a;18a;		2		1	50.00	50.00	2		1	45	45
H5521	093	0	1	04	01	H5521_093_0	7	11	$0	11	14a;	14b;	2		1	0.00	0.00	2		2		
H5521	093	0	1	04	01	H5521_093_0	7	12	$350- Comprehensive Dental Allowance	10		16b;	2		1	0.00	0.00	2		2		
H5521	093	0	1	04	01	H5521_093_0	7	2	$50 Copay	01	3-3;7a;7d;7f;16b;		2		1	50.00	50.00	2		2		
H5521	093	0	1	04	01	H5521_093_0	7	3	$264 Copay	01	9a;9b;		2		1	264.00	264.00	2		2		
H5521	093	0	1	04	01	H5521_093_0	7	7	$150 Allowance	10		16a;	2		1	0.00	0.00	2		2		
H5521	093	0	1	04	01	H5521_093_0	7	8	$125 Allowance	10		17b;	2		1	0.00	0.00	2		2		
H5521	093	0	1	04	01	H5521_093_0	7	9	$300 Allowance	10		18b;	2		2			2		2		
H5521	093	0	1	04	01	H5521_093_0	7	4	20%	01	12;14d;		2		2			2		1	20	20
H5521	093	0	1	04	01	H5521_093_0	7	5	$350- Ambulance	01	10a;		2		1	350.00	350.00	2		2		
H5521	093	0	1	04	01	H5521_093_0	7	6	14C- $0-$75 copay fitness	10		14c;	2		1	0.00	75.00	2		2		
H5521	094	0	1	04	01	H5521_094_0	6	8	$125 Allowance	10		17b;	2		2			2		2		
H5521	094	0	1	04	01	H5521_094_0	6	9	$300 Allowance	10		18b;	2		2			2		2		
H5521	094	0	1	04	01	H5521_094_0	6	1	45%	11	3-1;3-2;5;6;7b;7c;7e;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9c;9d;11a;11c;14e;15;17b;	9d;17a;18a;	2		2			2		1	45	45
H5521	094	0	1	04	01	H5521_094_0	6	10	$35 to 45% coisurance	01	11b;		2		1	35.00	35.00	2		1	45	45
H5521	094	0	1	04	01	H5521_094_0	6	11	$0	11	14a;	14b;	2		1	0.00	0.00	2		2		
H5521	094	0	1	04	01	H5521_094_0	6	12	$850 Allowance- Comp Dental	10		16b;	2		1	0.00	0.00	2		2		
H5521	094	0	1	04	01	H5521_094_0	6	2	$35 Copay	01	3-3;7a;7d;7f;16b;17a;18a;		2		1	35.00	35.00	2		2		
H5521	094	0	1	04	01	H5521_094_0	6	3	$264 Copay	01	9a;9b;		2		1	264.00	264.00	2		2		
H5521	094	0	1	04	01	H5521_094_0	6	4	20%	01	12;14d;		2		2			2		1	20	20
H5521	094	0	1	04	01	H5521_094_0	6	5	$350	01	10a;		2		1	350.00	350.00	2		2		
H5521	094	0	1	04	01	H5521_094_0	6	6	14C- $0-$75 copay fitness	10		14c;	2		1	0.00	75.00	2		2		
H5521	094	0	1	04	01	H5521_094_0	6	7	$150 Allowance	10		16a;	2		2			2		2		
H5521	095	0	1	04	01	H5521_095_0	4	1	20%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	20	20
H5521	095	0	1	04	01	H5521_095_0	4	2	$300 Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H5521	095	0	1	04	01	H5521_095_0	4	3	$0 - $75	10		14c;	2		1	0.00	75.00	2		2		
H5521	095	0	1	04	01	H5521_095_0	4	4	Eyewear	10		17b;	2		1	0.00	0.00	2		2		
H5521	095	0	1	04	01	H5521_095_0	4	5	Hearing Aids	10		18b;	2		1	0.00	0.00	2		2		
H5521	095	0	1	04	01	H5521_095_0	4	6	Preventive Dental	10		16a;	2		2			1	75.00	1	30	30
H5521	095	0	1	04	01	H5521_095_0	4	7	0%-20%	01	14a;		2		2			2		1	0	20
H5521	098	0	1	04	01	H5521_098_0	4	1	40% Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	40	40
H5521	098	0	1	04	01	H5521_098_0	4	2	Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H5521	098	0	1	04	01	H5521_098_0	4	6	14c Supplemental Benefits	10		14c;	2		1	0.00	75.00	2		2		
H5521	098	0	1	04	01	H5521_098_0	4	5	Medicare-covered Preventive Services	01	14a;		2		2			2		1	0	40
H5521	098	0	1	04	01	H5521_098_0	4	4	$0 Copayment Group	10		16a;17b;18b;	2		1	0.00	0.00	2		2		
H5521	098	0	1	04	01	H5521_098_0	4	3	20% OON Group	01	12;14d;		2		2			2		1	20	20
H5521	099	0	1	04	01	H5521_099_0	5	4	14c	10		14c;	2		1	0.00	75.00	2		1	50	50
H5521	099	0	1	04	01	H5521_099_0	5	3	20%	01	12;		2		2			2		1	20	20
H5521	099	0	1	04	01	H5521_099_0	5	2	$300	01	10a;		2		1	300.00	300.00	2		2		
H5521	099	0	1	04	01	H5521_099_0	5	1	50%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	50	50
H5521	099	0	1	04	01	H5521_099_0	5	5	0-50%	01	14a;		2		2			2		1	0	50
H5521	100	0	1	04	01	H5521_100_0	6	4	OON Range	01	14a;		2		2			2		1	0	40
H5521	100	0	1	04	01	H5521_100_0	6	1	40% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	40	40
H5521	100	0	1	04	01	H5521_100_0	6	5	Extra Benefits Range	10		14c;	2		1	0.00	75.00	2		2		
H5521	100	0	1	04	01	H5521_100_0	6	3	$0 copay	10		16a;17b;18b;	2		1	0.00	0.00	2		2		
H5521	100	0	1	04	01	H5521_100_0	6	2	$350 copay	01	10a;		2		1	350.00	350.00	2		2		
H5521	101	0	1	04	01	H5521_101_0	5	1	45% coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	45	45
H5521	101	0	1	04	01	H5521_101_0	5	2	$350 copay	01	10a;		2		1	350.00	350.00	2		2		
H5521	101	0	1	04	01	H5521_101_0	5	3	$0 copay	10		16a;16b;17b;18b;	2		1	0.00	0.00	2		2		
H5521	101	0	1	04	01	H5521_101_0	5	4	OON Range	01	14a;		2		2			2		1	0	45
H5521	101	0	1	04	01	H5521_101_0	5	5	Extra Benefits Range	10		14c;	2		1	0.00	75.00	2		2		
H5521	102	0	1	04	01	H5521_102_0	4	3	20%	01	12;14d;		2		2			2		1	20	20
H5521	102	0	1	04	01	H5521_102_0	4	2	$350	01	10a;		2		1	350.00	350.00	2		2		
H5521	102	0	1	04	01	H5521_102_0	4	1	40%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	40	40
H5521	102	0	1	04	01	H5521_102_0	4	4	$0 - $75	10		14c;	2		1	0.00	75.00	2		2		
H5521	102	0	1	04	01	H5521_102_0	4	5	0%-40%	01	14a;		2		2			2		1	0	40
H5521	103	0	1	04	01	H5521_103_0	7	1	45 % Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;17b;18a;	2		2			2		1	45	45
H5521	103	0	1	04	01	H5521_103_0	7	2	Ambulance	01	10a;		2		1	350.00	350.00	2		2		
H5521	103	0	1	04	01	H5521_103_0	7	3	20 % Tier	01	12;14d;		2		2			2		1	20	20
H5521	103	0	1	04	01	H5521_103_0	7	4	0% for 14C and $75 for OON Fitness	10		14c;	2		1	0.00	75.00	2		1	0	0
H5521	103	0	1	04	01	H5521_103_0	7	5	Dental Allowance	10		16a;	2		1	0.00	0.00	2		2		
H5521	103	0	1	04	01	H5521_103_0	7	6	14A	01	14a;		2		2			2		1	0	45
H5521	104	0	1	04	01	H5521_104_0	8	1	45 % Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;17b;18a;	2		2			2		1	45	45
H5521	104	0	1	04	01	H5521_104_0	8	2	Ambulance	01	10a;		2		1	350.00	350.00	2		2		
H5521	104	0	1	04	01	H5521_104_0	8	3	20 % Tier	01	12;14d;		2		2			2		1	20	20
H5521	104	0	1	04	01	H5521_104_0	8	4	0% for 14C and $75 for OON Fitness	10		14c;	2		1	0.00	75.00	2		1	0	0
H5521	104	0	1	04	01	H5521_104_0	8	5	Dental Allowance	10		16a;	2		1	0.00	0.00	2		2		
H5521	104	0	1	04	01	H5521_104_0	8	6	14A	01	14a;		2		2			2		1	0	45
H5521	105	0	1	04	01	H5521_105_0	8	4	0% for 14C and $75 for OON Fitness	10		14c;	2		1	0.00	75.00	2		1	0	0
H5521	105	0	1	04	01	H5521_105_0	8	6	14A	01	14a;		2		2			2		1	0	45
H5521	105	0	1	04	01	H5521_105_0	8	5	Dental Allowance	10		16a;	2		1	0.00	0.00	2		2		
H5521	105	0	1	04	01	H5521_105_0	8	1	45 % Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;17b;18a;	2		2			2		1	45	45
H5521	105	0	1	04	01	H5521_105_0	8	3	20 % Tier	01	12;14d;		2		2			2		1	20	20
H5521	105	0	1	04	01	H5521_105_0	8	2	Ambulance	01	10a;		2		1	350.00	350.00	2		2		
H5521	106	0	1	04	01	H5521_106_0	8	4	0% for 14C and $75 for OON Fitness	10		14c;	2		1	0.00	75.00	2		1	0	0
H5521	106	0	1	04	01	H5521_106_0	8	3	20 % Tier	01	12;14d;		2		2			2		1	20	20
H5521	106	0	1	04	01	H5521_106_0	8	1	45 % Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;17b;18a;	2		2			2		1	45	45
H5521	106	0	1	04	01	H5521_106_0	8	2	Ambulance	01	10a;		2		1	350.00	350.00	2		2		
H5521	106	0	1	04	01	H5521_106_0	8	6	14A	01	14a;		2		2			2		1	0	45
H5521	106	0	1	04	01	H5521_106_0	8	5	Dental Allowance	10		16a;	2		1	0.00	0.00	2		2		
H5521	107	0	1	04	01	H5521_107_0	5	5	Dental Allowance	10		16a;	2		1	0.00	0.00	2		2		
H5521	107	0	1	04	01	H5521_107_0	5	4	0% for 14C and $75 for OON Fitness	10		14c;	2		1	0.00	75.00	2		1	0	0
H5521	107	0	1	04	01	H5521_107_0	5	3	20 % Tier	01	12;14d;		2		2			2		1	20	20
H5521	107	0	1	04	01	H5521_107_0	5	2	Ambulance	01	10a;		2		1	350.00	350.00	2		2		
H5521	107	0	1	04	01	H5521_107_0	5	1	45 % Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;17b;18a;	2		2			2		1	45	45
H5521	107	0	1	04	01	H5521_107_0	5	6	14A	01	14a;		2		2			2		1	0	45
H5521	108	0	1	04	01	H5521_108_0	9	5	Dental Allowance	10		16a;	2		1	0.00	0.00	2		2		
H5521	108	0	1	04	01	H5521_108_0	9	4	0% for 14C and $75 for OON Fitness	10		14c;	2		1	0.00	75.00	2		1	0	0
H5521	108	0	1	04	01	H5521_108_0	9	3	20 % Tier	01	12;14d;		2		2			2		1	20	20
H5521	108	0	1	04	01	H5521_108_0	9	2	Ambulance	01	10a;		2		1	350.00	350.00	2		2		
H5521	108	0	1	04	01	H5521_108_0	9	1	45 % Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;17b;18a;	2		2			2		1	45	45
H5521	108	0	1	04	01	H5521_108_0	9	6	14A	01	14a;		2		2			2		1	0	45
H5521	109	0	1	04	01	H5521_109_0	5	1	45 % Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;17b;18a;	2		2			2		1	45	45
H5521	109	0	1	04	01	H5521_109_0	5	2	Ambulance	01	10a;		2		1	350.00	350.00	2		2		
H5521	109	0	1	04	01	H5521_109_0	5	3	20 % Tier	01	12;14d;		2		2			2		1	20	20
H5521	109	0	1	04	01	H5521_109_0	5	4	0% for 14C and $75 for OON Fitness	10		14c;	2		1	0.00	75.00	2		1	0	0
H5521	109	0	1	04	01	H5521_109_0	5	5	Dental Allowance	10		16a;	2		1	0.00	0.00	2		2		
H5521	109	0	1	04	01	H5521_109_0	5	6	14A	01	14a;		2		2			2		1	0	45
H5521	110	0	1	04	01	H5521_110_0	6	1	40% Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	40	40
H5521	110	0	1	04	01	H5521_110_0	6	2	Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H5521	110	0	1	04	01	H5521_110_0	6	3	20% OON Group	01	12;14d;		2		2			2		1	20	20
H5521	110	0	1	04	01	H5521_110_0	6	5	Medicare-covered Preventive Services	01	14a;		2		2			2		1	0	40
H5521	110	0	1	04	01	H5521_110_0	6	4	$0 Copayment Group	10		16a;	2		1	0.00	0.00	2		2		
H5521	110	0	1	04	01	H5521_110_0	6	6	14c Supplemental Benefits	10		14c;	2		1	0.00	75.00	2		2		
H5521	111	0	1	04	01	H5521_111_0	5	2	Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H5521	111	0	1	04	01	H5521_111_0	5	3	20% OON Group	01	12;14d;		2		2			2		1	20	20
H5521	111	0	1	04	01	H5521_111_0	5	4	14c Supplemental Benefits	10		14c;	2		1	0.00	75.00	2		2		
H5521	111	0	1	04	01	H5521_111_0	5	5	Medicare-covered Preventive Services	01	14a;		2		2			2		1	0	40
H5521	111	0	1	04	01	H5521_111_0	5	1	40% Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	40	40
H5521	112	0	1	04	01	H5521_112_0	4	1	40% Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	40	40
H5521	112	0	1	04	01	H5521_112_0	4	2	Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H5521	112	0	1	04	01	H5521_112_0	4	3	20% OON Group	01	12;14d;		2		2			2		1	20	20
H5521	112	0	1	04	01	H5521_112_0	4	4	$0 Copayment Group	10		17b;18b;	2		1	0.00	0.00	2		2		
H5521	112	0	1	04	01	H5521_112_0	4	5	Medicare-covered Preventive Services	01	14a;		2		2			2		1	0	40
H5521	112	0	1	04	01	H5521_112_0	4	6	14c Supplemental Benefits	10		14c;	2		1	0.00	75.00	2		2		
H5521	113	0	1	04	01	H5521_113_0	4	1	40% Coinsurance Group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	40	40
H5521	113	0	1	04	01	H5521_113_0	4	2	Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H5521	113	0	1	04	01	H5521_113_0	4	3	20% OON Group	01	12;14d;		2		2			2		1	20	20
H5521	113	0	1	04	01	H5521_113_0	4	4	$0 Copayment Group	10		16a;17b;18b;	2		1	0.00	0.00	2		2		
H5521	113	0	1	04	01	H5521_113_0	4	5	Medicare-covered Preventive Services	01	14a;		2		2			2		1	0	40
H5521	113	0	1	04	01	H5521_113_0	4	6	14c Supplemental Benefits	10		14c;	2		1	0.00	75.00	2		2		
H5521	801	0	1	04	01	H5521_801_0	6	1		01	6;14a;		2		2			2		1	0	0
H5521	801	0	1	04	01	H5521_801_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5521	802	0	1	04	01	H5521_802_0	5	1		01	6;14a;		2		2			2		1	0	0
H5521	802	0	1	04	01	H5521_802_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5521	805	0	2	04	01	H5521_805_0	5	1		01	6;14a;		2		2			2		1	0	0
H5521	805	0	2	04	01	H5521_805_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5521	806	0	2	04	01	H5521_806_0	3	1		01	6;14a;		2		2			2		1	0	0
H5521	806	0	2	04	01	H5521_806_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5522	001	0	1	04	01	H5522_001_0	7	3	NO COST SHARING	01	6;		2		2			2		2		
H5522	001	0	1	04	01	H5522_001_0	7	7	NON MEDICARE COVERED DENTAL	10		16b;	2		2			1	100.00	1	50	50
H5522	001	0	1	04	01	H5522_001_0	7	8	30% Preventive Dental	10		16a;	2		2			1	100.00	1	30	30
H5522	001	0	1	04	01	H5522_001_0	7	9	NON-MEDICARE COVERED EYEWEAR	10		17b;	2		2			2		2		
H5522	001	0	1	04	01	H5522_001_0	7	4	20%	01	11a;11b;11c;14d;14e;		2		2			2		1	20	20
H5522	001	0	1	04	01	H5522_001_0	7	5	0-20%	01	14a;		2		2			2		1	0	20
H5522	001	0	1	04	01	H5522_001_0	7	6	0-$50	10		14c;	2		1	0.00	50.00	2		2		
H5522	001	0	1	04	01	H5522_001_0	7	1	30%	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;10a;12;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		2			2		1	30	30
H5522	001	0	1	04	01	H5522_001_0	7	10	50% HEARING AIDS	10		18b;	2		2			2		1	50	50
H5522	001	0	1	04	01	H5522_001_0	7	2	45%	01	5;7e;7h;9c;		2		2			2		1	45	45
H5522	002	0	1	04	01	H5522_002_0	6	1	30%	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		2			2		1	30	30
H5522	002	0	1	04	01	H5522_002_0	6	2	45%	01	5;7e;7h;9c;		2		2			2		1	45	45
H5522	002	0	1	04	01	H5522_002_0	6	3	NO COST SHARE	01	6;		2		2			2		2		
H5522	002	0	1	04	01	H5522_002_0	6	4	0-30%	01	14a;		2		2			2		1	0	30
H5522	002	0	1	04	01	H5522_002_0	6	5	0-$50	10		14c;	2		1	0.00	50.00	2		2		
H5522	002	0	1	04	01	H5522_002_0	6	6	Preventive Dental	10		16a;	2		2			1	100.00	1	30	30
H5522	002	0	1	04	01	H5522_002_0	6	8	NO COST SHARE	10		17b;	2		2			2		2		
H5522	002	0	1	04	01	H5522_002_0	6	7	Comprehensive Dental	10		16b;	2		2			1	100.00	1	50	50
H5522	004	0	1	04	01	H5522_004_0	3	3	45%	01	5;7e;7h;9c;		2		2			2		1	45	45
H5522	004	0	1	04	01	H5522_004_0	3	6	$0-$50	10		14c;	2		1	0.00	50.00	2		2		
H5522	004	0	1	04	01	H5522_004_0	3	5	0-40%	01	14a;		2		2			2		1	0	40
H5522	004	0	1	04	01	H5522_004_0	3	4	25%	01	11a;11b;11c;		2		2			2		1	25	25
H5522	004	0	1	04	01	H5522_004_0	3	2	NO COST SHARING	01	6;		2		2			2		2		
H5522	004	0	1	04	01	H5522_004_0	3	1	40%	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;10a;12;14d;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		2			2		1	40	40
H5522	005	0	1	04	01	H5522_005_0	3	4	0-25%	01	14a;		2		2			2		1	0	25
H5522	005	0	1	04	01	H5522_005_0	3	5	$0-$50	10		14c;	2		1	0.00	50.00	2		2		
H5522	005	0	1	04	01	H5522_005_0	3	6	25%	01	14d;14e;		2		2			2		1	25	25
H5522	005	0	1	04	01	H5522_005_0	3	3	NO COST SHARING	01	6;		2		2			2		2		
H5522	005	0	1	04	01	H5522_005_0	3	2	45%	01	5;7e;7h;9c;		2		2			2		1	45	45
H5522	005	0	1	04	01	H5522_005_0	3	1	30%	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;10a;11a;11b;11c;12;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		2			2		1	30	30
H5522	013	0	1	04	01	H5522_013_0	5	5	NO COST SHARE	01	6;		2		2			2		2		
H5522	013	0	1	04	01	H5522_013_0	5	6	NON-MEDICARE COVERED EYEWARE	10		17b;	2		2			2		2		
H5522	013	0	1	04	01	H5522_013_0	5	7	PREVENTIVE DENTAL	10		16a;	2		2			2		2		
H5522	013	0	1	04	01	H5522_013_0	5	4	$0-$50	10		14c;	2		1	0.00	50.00	2		2		
H5522	013	0	1	04	01	H5522_013_0	5	3	0-40%	01	14a;		2		2			2		1	0	40
H5522	013	0	1	04	01	H5522_013_0	5	2	45%	01	5;7e;7h;9c;		2		2			2		1	45	45
H5522	013	0	1	04	01	H5522_013_0	5	1	40%	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		2			2		1	40	40
H5522	014	0	1	04	01	H5522_014_0	6	10	Preventive Dental	10		16a;	2		2			1	100.00	1	30	30
H5522	014	0	1	04	01	H5522_014_0	6	9	NON-MEDICARE COMP DENTAL	10		16b;	2		2			1	100.00	1	50	50
H5522	014	0	1	04	01	H5522_014_0	6	8	NON MEDICARE COVERED EYEWEAR	10		17b;	2		2			2		2		
H5522	014	0	1	04	01	H5522_014_0	6	7	$0-$50	10		14c;	2		1	0.00	50.00	2		2		
H5522	014	0	1	04	01	H5522_014_0	6	6	0-20%	01	14a;		2		2			2		1	0	20
H5522	014	0	1	04	01	H5522_014_0	6	5	NO COST SHARING	01	6;		2		2			2		2		
H5522	014	0	1	04	01	H5522_014_0	6	4	45%	01	5;7e;7h;9c;		2		2			2		1	45	45
H5522	014	0	1	04	01	H5522_014_0	6	3	40%	01	11a;11b;11c;15;		2		2			2		1	40	40
H5522	014	0	1	04	01	H5522_014_0	6	2	30%	01	10a;12;		2		2			2		1	30	30
H5522	014	0	1	04	01	H5522_014_0	6	1	20%	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;14d;14e;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		2			2		1	20	20
H5522	015	0	1	04	01	H5522_015_0	8	1	30%	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;10a;12;14d;14e;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		2			2		1	30	30
H5522	015	0	1	04	01	H5522_015_0	8	9	NON MEDICARE COMP DENTAL	10		16b;	2		2			1	100.00	1	50	50
H5522	015	0	1	04	01	H5522_015_0	8	8	NON MEDICARE COVERED EYEWEAR	10		17b;	2		2			2		2		
H5522	015	0	1	04	01	H5522_015_0	8	7	$0-$50	10		14c;	2		1	0.00	50.00	2		2		
H5522	015	0	1	04	01	H5522_015_0	8	6	0-20%	01	14a;		2		2			2		1	0	20
H5522	015	0	1	04	01	H5522_015_0	8	5	NO COST SHARING	01	6;		2		2			2		2		
H5522	015	0	1	04	01	H5522_015_0	8	4	45%	01	5;7e;7h;9c;		2		2			2		1	45	45
H5522	015	0	1	04	01	H5522_015_0	8	10	Preventive Dental	10		16a;	2		2			1	100.00	1	30	30
H5522	015	0	1	04	01	H5522_015_0	8	2	20%	01	15;		2		2			2		1	20	20
H5522	015	0	1	04	01	H5522_015_0	8	3	40%	01	11a;11b;11c;		2		2			2		1	40	40
H5522	017	0	1	04	01	H5522_017_0	3	3	NO COST SHARING	01	6;		2		2			2		2		
H5522	017	0	1	04	01	H5522_017_0	3	2	45%	01	5;9c;		2		2			2		1	45	45
H5522	017	0	1	04	01	H5522_017_0	3	1	40%	11	3-1;3-2;3-3;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;10a;12;14d;14e;15;16b;17a;17b;18a;	9d;17a;18a;	2		2			2		1	40	40
H5522	017	0	1	04	01	H5522_017_0	3	5	25%	01	11a;11b;11c;		2		2			2		1	25	25
H5522	017	0	1	04	01	H5522_017_0	3	6	0-40%	01	14a;		2		2			2		1	0	40
H5522	017	0	1	04	01	H5522_017_0	3	4	20%	11	7a;7b;7c;7d;7e;7f;7g;7h;7i;	7f;14b;	2		2			2		1	20	20
H5522	017	0	1	04	01	H5522_017_0	3	7	$0-$50	10		14c;	2		1	0.00	50.00	2		2		
H5522	018	0	1	04	01	H5522_018_0	3	1	40%	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;10a;12;14d;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		2			2		1	40	40
H5522	018	0	1	04	01	H5522_018_0	3	2	45%	01	5;7e;7h;9c;		2		2			2		1	45	45
H5522	018	0	1	04	01	H5522_018_0	3	3	NO COST SHARING	01	6;		2		2			2		2		
H5522	018	0	1	04	01	H5522_018_0	3	4	25%	01	11a;11b;11c;		2		2			2		1	25	25
H5522	018	0	1	04	01	H5522_018_0	3	6	$0- $50	10		14c;	2		1	0.00	50.00	2		2		
H5522	018	0	1	04	01	H5522_018_0	3	5	0-40%	01	14a;		2		2			2		1	0	40
H5522	802	0	1	04	01	H5522_802_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5522	802	0	1	04	01	H5522_802_0	3	1		01	6;14a;		2		2			2		1	0	0
H5522	803	0	1	04	01	H5522_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5522	803	0	1	04	01	H5522_803_0	2	1		01	6;14a;		2		2			2		1	0	0
H5525	004	0	1	04	01	H5525_004_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H5525	004	0	1	04	01	H5525_004_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5525	004	0	1	04	01	H5525_004_0	3	3		10		18a;	2		1	35.00	35.00	2		2		
H5525	004	0	1	04	01	H5525_004_0	3	4		01	12;		2		2			2		1	20	20
H5525	004	0	1	04	01	H5525_004_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;16b;17a;18a;	7f;13c;13d;14b;14c;16a;16b;	2		2			2		1	50	50
H5525	004	0	1	04	01	H5525_004_0	3	6		10		13b;	1	15.00	2			2		1	50	50
H5525	005	0	1	04	01	H5525_005_0	3	7		10		13b;	1	20.00	2			2		1	50	50
H5525	005	0	1	04	01	H5525_005_0	3	6		10		13c;14c;16a;16b;	2		2			2		1	50	50
H5525	005	0	1	04	01	H5525_005_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H5525	005	0	1	04	01	H5525_005_0	3	4		01	14a;		2		2			2		1	0	30
H5525	005	0	1	04	01	H5525_005_0	3	3		01	12;		2		2			2		1	0	20
H5525	005	0	1	04	01	H5525_005_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H5525	005	0	1	04	01	H5525_005_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5525	006	0	1	04	01	H5525_006_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H5525	006	0	1	04	01	H5525_006_0	3	6		01	15;		2		2			2		1	20	30
H5525	006	0	1	04	01	H5525_006_0	3	9		10		13b;	1	20.00	2			2		1	50	50
H5525	006	0	1	04	01	H5525_006_0	3	8		10		13c;14c;16a;16b;	2		2			2		1	50	50
H5525	006	0	1	04	01	H5525_006_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H5525	006	0	1	04	01	H5525_006_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5525	006	0	1	04	01	H5525_006_0	3	3		01	12;		2		2			2		1	0	20
H5525	006	0	1	04	01	H5525_006_0	3	4		01	14a;		2		2			2		1	0	30
H5525	006	0	1	04	01	H5525_006_0	3	5		01	11a;		2		2			2		1	20	20
H5525	007	0	1	04	01	H5525_007_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H5525	007	0	1	04	01	H5525_007_0	3	8		10		13c;14c;16a;16b;	2		2			2		1	50	50
H5525	007	0	1	04	01	H5525_007_0	3	9		10		13b;	1	20.00	2			2		1	50	50
H5525	007	0	1	04	01	H5525_007_0	3	6		01	15;		2		2			2		1	20	30
H5525	007	0	1	04	01	H5525_007_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H5525	007	0	1	04	01	H5525_007_0	3	4		01	14a;		2		2			2		1	0	30
H5525	007	0	1	04	01	H5525_007_0	3	3		01	12;		2		2			2		1	0	20
H5525	007	0	1	04	01	H5525_007_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5525	007	0	1	04	01	H5525_007_0	3	5		01	11a;		2		2			2		1	20	20
H5525	008	0	1	04	01	H5525_008_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H5525	008	0	1	04	01	H5525_008_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5525	008	0	1	04	01	H5525_008_0	3	3		01	12;		2		2			2		1	0	20
H5525	008	0	1	04	01	H5525_008_0	3	4		01	14a;		2		2			2		1	0	30
H5525	008	0	1	04	01	H5525_008_0	3	5		01	15;		2		2			2		1	20	30
H5525	008	0	1	04	01	H5525_008_0	3	6		01	11a;		2		2			2		1	27	27
H5525	008	0	1	04	01	H5525_008_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H5525	008	0	1	04	01	H5525_008_0	3	8		10		13c;14c;16a;16b;	2		2			2		1	50	50
H5525	008	0	1	04	01	H5525_008_0	3	9		10		13b;	1	15.00	2			2		1	50	50
H5525	009	0	1	04	01	H5525_009_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H5525	009	0	1	04	01	H5525_009_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5525	009	0	1	04	01	H5525_009_0	3	3		01	14a;		2		2			2		1	0	30
H5525	009	0	1	04	01	H5525_009_0	3	8		10		13b;	1	15.00	2			2		1	50	50
H5525	009	0	1	04	01	H5525_009_0	3	5		01	11a;		2		2			2		1	27	27
H5525	009	0	1	04	01	H5525_009_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H5525	009	0	1	04	01	H5525_009_0	3	7		10		13c;14c;16a;16b;	2		2			2		1	50	50
H5525	009	0	1	04	01	H5525_009_0	3	4		01	12;15;		2		2			2		1	20	20
H5525	015	0	1	04	01	H5525_015_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H5525	015	0	1	04	01	H5525_015_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5525	015	0	1	04	01	H5525_015_0	3	8		10		13b;	1	20.00	2			2		1	50	50
H5525	015	0	1	04	01	H5525_015_0	3	7		10		14c;	2		2			2		1	50	50
H5525	015	0	1	04	01	H5525_015_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H5525	015	0	1	04	01	H5525_015_0	3	5		01	11a;11c;		2		2			2		1	25	25
H5525	015	0	1	04	01	H5525_015_0	3	4		01	12;		2		2			2		1	20	20
H5525	015	0	1	04	01	H5525_015_0	3	3		01	14a;		2		2			2		1	0	30
H5525	017	0	1	04	01	H5525_017_0	3	4		01	14a;		2		2			2		1	0	30
H5525	017	0	1	04	01	H5525_017_0	3	3		01	12;		2		2			2		1	0	20
H5525	017	0	1	04	01	H5525_017_0	3	7		10		13b;	1	20.00	2			2		1	50	50
H5525	017	0	1	04	01	H5525_017_0	3	6		10		13c;14c;16a;	2		2			2		1	50	50
H5525	017	0	1	04	01	H5525_017_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5525	017	0	1	04	01	H5525_017_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H5525	017	0	1	04	01	H5525_017_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H5525	020	0	1	04	01	H5525_020_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H5525	020	0	1	04	01	H5525_020_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5525	020	0	1	04	01	H5525_020_0	3	3		01	14a;		2		2			2		1	0	30
H5525	020	0	1	04	01	H5525_020_0	3	4		01	11a;11c;12;		2		2			2		1	20	20
H5525	020	0	1	04	01	H5525_020_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H5525	020	0	1	04	01	H5525_020_0	3	6		10		13c;14c;	2		2			2		1	50	50
H5525	020	0	1	04	01	H5525_020_0	3	7		10		13b;	1	15.00	2			2		1	50	50
H5525	021	0	1	04	01	H5525_021_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H5525	021	0	1	04	01	H5525_021_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5525	021	0	1	04	01	H5525_021_0	3	3		01	14a;		2		2			2		1	0	30
H5525	021	0	1	04	01	H5525_021_0	3	4		01	8b2;12;		2		2			2		1	20	20
H5525	021	0	1	04	01	H5525_021_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b3;9a;9b;9c;11a;11b;11c;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H5525	021	0	1	04	01	H5525_021_0	3	6		10		13c;14c;	2		2			2		1	50	50
H5525	021	0	1	04	01	H5525_021_0	3	7		10		13b;	1	20.00	2			2		1	50	50
H5525	022	0	1	04	01	H5525_022_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H5525	022	0	1	04	01	H5525_022_0	3	7		10		13b;	1	20.00	2			2		1	50	50
H5525	022	0	1	04	01	H5525_022_0	3	6		10		13c;14c;	2		2			2		1	50	50
H5525	022	0	1	04	01	H5525_022_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b3;9a;9b;9c;11a;11b;11c;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H5525	022	0	1	04	01	H5525_022_0	3	4		01	8b2;12;		2		2			2		1	20	20
H5525	022	0	1	04	01	H5525_022_0	3	3		01	14a;		2		2			2		1	0	30
H5525	022	0	1	04	01	H5525_022_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5525	023	0	1	04	01	H5525_023_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H5525	023	0	1	04	01	H5525_023_0	3	7		10		13c;14c;16a;16b;	2		2			2		1	50	50
H5525	023	0	1	04	01	H5525_023_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H5525	023	0	1	04	01	H5525_023_0	3	5		01	15;		2		2			2		1	20	30
H5525	023	0	1	04	01	H5525_023_0	3	4		01	14a;		2		2			2		1	0	30
H5525	023	0	1	04	01	H5525_023_0	3	3		01	12;		2		2			2		1	0	20
H5525	023	0	1	04	01	H5525_023_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5525	023	0	1	04	01	H5525_023_0	3	8		10		13b;	1	20.00	2			2		1	50	50
H5525	024	0	1	04	01	H5525_024_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H5525	024	0	1	04	01	H5525_024_0	3	8		10		13b;	1	15.00	2			2		1	50	50
H5525	024	0	1	04	01	H5525_024_0	3	7		10		13c;14c;16a;16b;	2		2			2		1	50	50
H5525	024	0	1	04	01	H5525_024_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H5525	024	0	1	04	01	H5525_024_0	3	5		01	11a;11b;11c;		2		2			2		1	25	25
H5525	024	0	1	04	01	H5525_024_0	3	4		01	12;		2		2			2		1	20	20
H5525	024	0	1	04	01	H5525_024_0	3	3		01	14a;		2		2			2		1	0	30
H5525	024	0	1	04	01	H5525_024_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5525	025	0	1	04	01	H5525_025_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5525	025	0	1	04	01	H5525_025_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H5525	025	0	1	04	01	H5525_025_0	3	3		01	14a;		2		2			2		1	0	30
H5525	025	0	1	04	01	H5525_025_0	3	4		01	12;		2		2			2		1	20	20
H5525	025	0	1	04	01	H5525_025_0	3	5		01	11a;11b;11c;		2		2			2		1	25	25
H5525	025	0	1	04	01	H5525_025_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H5525	025	0	1	04	01	H5525_025_0	3	7		10		13c;14c;	2		2			2		1	50	50
H5525	025	0	1	04	01	H5525_025_0	3	8		10		13b;	1	15.00	2			2		1	50	50
H5525	026	0	1	04	01	H5525_026_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5525	026	0	1	04	01	H5525_026_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H5525	026	0	1	04	01	H5525_026_0	3	3		01	14a;		2		2			2		1	0	35
H5525	026	0	1	04	01	H5525_026_0	3	7		10		13b;	1	15.00	2			2		1	50	50
H5525	026	0	1	04	01	H5525_026_0	3	6		10		13c;14c;	2		2			2		1	50	50
H5525	026	0	1	04	01	H5525_026_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	35	35
H5525	026	0	1	04	01	H5525_026_0	3	4		01	11a;12;		2		2			2		1	20	20
H5525	027	0	1	04	01	H5525_027_0	3	5		01	12;		2		2			2		1	20	20
H5525	027	0	1	04	01	H5525_027_0	3	4		01	11a;		2		2			2		1	15	15
H5525	027	0	1	04	01	H5525_027_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;13d;14b;14c;	2		2			2		1	50	50
H5525	027	0	1	04	01	H5525_027_0	3	1		11	9d;	9d;	2		1	0.00	0.00	2		2		
H5525	027	0	1	04	01	H5525_027_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5525	027	0	1	04	01	H5525_027_0	3	3		01	14a;		2		2			2		1	0	50
H5525	027	0	1	04	01	H5525_027_0	3	7		10		13b;	1	10.00	2			2		1	50	50
H5525	030	0	1	04	01	H5525_030_0	3	2		01	8a1;8a2;17a;		2		1	0.00	90.00	2		2		
H5525	030	0	1	04	01	H5525_030_0	3	3		01	3-1;3-2;3-3;7c;7i;		2		1	10.00	40.00	2		2		
H5525	030	0	1	04	01	H5525_030_0	3	4		01	9b;		2		1	195.00	195.00	2		2		
H5525	030	0	1	04	01	H5525_030_0	3	5		01	7b;		2		1	20.00	20.00	2		2		
H5525	030	0	1	04	01	H5525_030_0	3	6		01	9a;		2		1	225.00	225.00	2		2		
H5525	030	0	1	04	01	H5525_030_0	3	12		11	11a;11b;12;15;	13c;14c;	2		2			2		1	20	20
H5525	030	0	1	04	01	H5525_030_0	3	13		01	8b2;		2		1	30.00	30.00	2		1	20	20
H5525	030	0	1	04	01	H5525_030_0	3	14		10		18a;18b;	2		2			2		1	25	25
H5525	030	0	1	04	01	H5525_030_0	3	15		10		13b;	1	15.00	2			2		1	50	50
H5525	030	0	1	04	01	H5525_030_0	3	1		11	6;9d;14a;14d;14e;17b;	9d;13d;14b;16a;16b;17a;17b;	2		1	0.00	0.00	2		2		
H5525	030	0	1	04	01	H5525_030_0	3	10		01	9c;		2		1	30.00	90.00	2		2		
H5525	030	0	1	04	01	H5525_030_0	3	11		01	11c;		2		1	10.00	10.00	2		1	10	20
H5525	030	0	1	04	01	H5525_030_0	3	7		01	5;7d;7e;7f;7g;7h;8b1;16b;18a;		2		1	30.00	225.00	2		2		
H5525	030	0	1	04	01	H5525_030_0	3	8		01	10a;		2		1	300.00	300.00	2		2		
H5525	030	0	1	04	01	H5525_030_0	3	9		01	7a;8b3;		2		1	5.00	90.00	2		2		
H5525	809	0	1	04	01	H5525_809_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5525	809	0	1	04	01	H5525_809_0	1	1		01	6;14a;		2		2			2		1	0	0
H5525	810	0	1	04	01	H5525_810_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5525	810	0	1	04	01	H5525_810_0	1	1		01	6;14a;		2		2			2		1	0	0
H5525	811	0	1	04	01	H5525_811_0	1	1		01	6;14a;		2		2			2		1	0	0
H5525	811	0	1	04	01	H5525_811_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5525	812	0	2	04	01	H5525_812_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5525	812	0	2	04	01	H5525_812_0	1	1		01	6;14a;		2		2			2		1	0	0
H5525	813	0	2	04	01	H5525_813_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5525	813	0	2	04	01	H5525_813_0	1	1		01	6;14a;		2		2			2		1	0	0
H5525	814	0	2	04	01	H5525_814_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5525	814	0	2	04	01	H5525_814_0	1	1		01	6;14a;		2		2			2		1	0	0
H5526	004	0	1	04	01	H5526_004_0	4	1	50% Group	01	5;7e;7h;9c;11a;11b;11c;		2		2			2		1	50	50
H5526	004	0	1	04	01	H5526_004_0	4	4	Ambulance	01	10a;		2		1	125.00	125.00	2		2		
H5526	004	0	1	04	01	H5526_004_0	4	2	25% Group	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;14a;14d;14e;15;16b;17a;17b;18a;	7f;9d;14b;14c;17a;	2		2			2		1	25	25
H5526	004	0	1	04	01	H5526_004_0	4	3	Renal Dialysis	01	12;		2		1	10.00	10.00	2		2		
H5526	014	0	1	04	01	H5526_014_0	4	4	Ambulance	01	10a;		2		1	125.00	125.00	2		2		
H5526	014	0	1	04	01	H5526_014_0	4	2	25% Group	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;14a;14d;14e;15;16b;17a;17b;18a;	7f;9d;14b;14c;17a;	2		2			2		1	25	25
H5526	014	0	1	04	01	H5526_014_0	4	3	Renal Dialysis	01	12;		2		1	10.00	10.00	2		2		
H5526	014	0	1	04	01	H5526_014_0	4	1	50% Group	01	5;7e;7h;9c;11a;11b;11c;		2		2			2		1	50	50
H5526	016	0	1	04	01	H5526_016_0	4	3	Renal Dialysis	01	12;		2		1	10.00	10.00	2		2		
H5526	016	0	1	04	01	H5526_016_0	4	1	50% Group	01	5;7e;7h;9c;11a;11b;11c;		2		2			2		1	50	50
H5526	016	0	1	04	01	H5526_016_0	4	4	Ambulance	01	10a;		2		1	175.00	175.00	2		2		
H5526	016	0	1	04	01	H5526_016_0	4	2	35% Group	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;14a;14d;14e;15;16b;17a;17b;18a;	7f;9d;14b;14c;17a;	2		2			2		1	35	35
H5526	017	0	1	04	01	H5526_017_0	5	1	50% Group	01	5;7e;7h;9c;11a;11b;11c;		2		2			2		1	50	50
H5526	017	0	1	04	01	H5526_017_0	5	2	35% Group	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;14a;14d;14e;15;16b;17a;17b;18a;	7f;9d;14b;14c;17a;	2		2			2		1	35	35
H5526	017	0	1	04	01	H5526_017_0	5	3	Renal Dialysis	01	12;		2		1	10.00	10.00	2		2		
H5526	017	0	1	04	01	H5526_017_0	5	4	Ambulance	01	10a;		2		1	175.00	175.00	2		2		
H5526	806	0	1	04	01	H5526_806_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5526	806	0	1	04	01	H5526_806_0	1	1		01	6;14a;		2		2			2		1	0	0
H5526	808	0	1	04	01	H5526_808_0	1	1		01	6;14a;		2		2			2		1	0	0
H5526	808	0	1	04	01	H5526_808_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5528	001	0	1	04	01	H5528_001_0	4	2	$0 Cost Sharing	01	6;14d;		2		1	0.00	0.00	2		2		
H5528	001	0	1	04	01	H5528_001_0	4	3	$75 Cost Sharing	01	10a;		2		1	75.00	75.00	2		2		
H5528	001	0	1	04	01	H5528_001_0	4	1	50% Cost Sharing	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14e;15;16b;17a;17b;18a;	7f;9d;14b;14c;16a;17a;17b;	2		2			2		1	50	50
H5528	004	0	1	04	01	H5528_004_0	4	2	$0 Cost Sharing	01	6;14d;		2		1	0.00	0.00	2		2		
H5528	004	0	1	04	01	H5528_004_0	4	1	50% Cost Sharing	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14e;15;16b;17a;17b;18a;	7f;9d;14b;14c;16a;17a;17b;	2		2			2		1	50	50
H5528	004	0	1	04	01	H5528_004_0	4	3	$75 Cost Sharing	01	10a;		2		1	75.00	75.00	2		2		
H5528	009	0	1	04	01	H5528_009_0	4	3	$75 Cost Sharing	01	10a;		2		1	75.00	75.00	2		2		
H5528	009	0	1	04	01	H5528_009_0	4	2	$0 Cost Sharing	01	6;14d;		2		1	0.00	0.00	2		2		
H5528	009	0	1	04	01	H5528_009_0	4	1	50% Cost Sharing	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14e;15;16b;17a;17b;18a;	7f;9d;14b;14c;16a;17a;17b;	2		2			2		1	50	50
H5528	018	0	1	04	01	H5528_018_0	5	4	$0 Cost Sharing	01	6;14d;		2		2			2		2		
H5528	018	0	1	04	01	H5528_018_0	5	2	OTC Benefit	10		13b;	1	15.00	2			2		2		
H5528	018	0	1	04	01	H5528_018_0	5	1	50% Cost Sharing	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14e;15;16b;17a;17b;18a;	7f;9d;14c;16a;17a;17b;	2		2			2		1	50	50
H5528	018	0	1	04	01	H5528_018_0	5	3	20% Cost Sharing	01	10a;		2		2			2		1	20	20
H5528	022	0	1	04	01	H5528_022_0	6	3	$150 Cost Sharing	01	10a;		2		1	150.00	150.00	2		2		
H5528	022	0	1	04	01	H5528_022_0	6	2	$0 Cost Sharing	01	6;14d;		2		1	0.00	0.00	2		2		
H5528	022	0	1	04	01	H5528_022_0	6	1	50% Cost Sharing	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14e;15;16b;17a;17b;18a;	7f;9d;14b;14c;16a;17a;17b;18a;18b;	2		2			2		1	50	50
H5528	023	0	1	04	01	H5528_023_0	5	3	$150 Cost Sharing	01	10a;		2		1	150.00	150.00	2		2		
H5528	023	0	1	04	01	H5528_023_0	5	1	50% Cost Sharing	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14e;15;16b;17a;17b;18a;	7f;9d;14b;14c;16a;17a;17b;18a;18b;	2		2			2		1	50	50
H5528	023	0	1	04	01	H5528_023_0	5	2	$0 Cost Sharing	01	6;14d;		2		1	0.00	0.00	2		2		
H5528	024	0	1	04	01	H5528_024_0	5	1	50% Cost Sharing	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14e;15;16b;17a;17b;18a;	7f;9d;14b;14c;16a;17a;17b;18a;18b;	2		2			2		1	50	50
H5528	024	0	1	04	01	H5528_024_0	5	2	$0 Cost Sharing	01	6;14d;		2		1	0.00	0.00	2		2		
H5528	024	0	1	04	01	H5528_024_0	5	3	$150 Cost Sharing	01	10a;		2		1	150.00	150.00	2		2		
H5528	025	0	1	04	01	H5528_025_0	6	2	$0 Cost Sharing	01	6;14d;		2		1	0.00	0.00	2		2		
H5528	025	0	1	04	01	H5528_025_0	6	1	50% Cost Sharing	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14e;15;16b;17a;17b;18a;	7f;9d;14b;14c;16a;17a;17b;18a;18b;	2		2			2		1	50	50
H5528	025	0	1	04	01	H5528_025_0	6	3	$150 Cost Sharing	01	10a;		2		1	150.00	150.00	2		2		
H5528	026	0	1	04	01	H5528_026_0	5	2	$0 Cost Sharing	01	6;14d;		2		1	0.00	0.00	2		2		
H5528	026	0	1	04	01	H5528_026_0	5	3	$150 Cost Sharing	01	10a;		2		1	150.00	150.00	2		2		
H5528	026	0	1	04	01	H5528_026_0	5	1	50% Cost Sharing	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14e;15;16b;17a;17b;18a;	7f;9d;14b;14c;16a;17a;17b;18a;18b;	2		2			2		1	50	50
H5528	807	0	1	04	01	H5528_807_0	3	2	40% Coinsurance	01	7e;7h;		2		2			2		1	40	40
H5528	807	0	1	04	01	H5528_807_0	3	3	0% Coinsurance	01	6;14a;		2		2			2		1	0	0
H5528	807	0	1	04	01	H5528_807_0	3	1	20%	01	3-1;3-2;3-3;5;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5530	006	1	1	04	01	H5530_006_1	10	1	$0	11	9d;16b;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H5530	006	1	1	04	01	H5530_006_1	10	2	20%	11	8b2;12;15;	16a;18a;	2		2			2		1	20	20
H5530	006	1	1	04	01	H5530_006_1	10	3	Ambulance	01	10a;		2		1	250.00	250.00	2		1	20	20
H5530	006	1	1	04	01	H5530_006_1	10	4	Diag/Rad	01	8a1;8b1;8b3;		2		2			2		1	40	40
H5530	006	1	1	04	01	H5530_006_1	10	9	Eligible Supplemental Benefits	10		14c;	1	95.00	1	0.00	0.00	2		2		
H5530	006	1	1	04	01	H5530_006_1	10	6	SPEC	11	7b;7c;7d;7e;7f;7h;7i;	14b;	2		1	60.00	60.00	2		2		
H5530	006	1	1	04	01	H5530_006_1	10	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;17a;18a;		2		2			2		1	40	40
H5530	006	1	1	04	01	H5530_006_1	10	8	$30	01	8a2;		2		1	30.00	30.00	2		2		
H5530	006	1	1	04	01	H5530_006_1	10	5	PCP	01	7a;7g;		2		1	40.00	40.00	2		2		
H5530	006	2	1	04	01	H5530_006_2	10	1	$0	11	9d;16b;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H5530	006	2	1	04	01	H5530_006_2	10	2	20%	11	8b2;12;15;	16a;18a;	2		2			2		1	20	20
H5530	006	2	1	04	01	H5530_006_2	10	9	Eligible Supplemental Benefits	10		14c;	1	95.00	1	0.00	0.00	2		2		
H5530	006	2	1	04	01	H5530_006_2	10	8	$30	01	8a2;		2		1	30.00	30.00	2		2		
H5530	006	2	1	04	01	H5530_006_2	10	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;17a;18a;		2		2			2		1	40	40
H5530	006	2	1	04	01	H5530_006_2	10	3	Ambulance	01	10a;		2		1	250.00	250.00	2		1	20	20
H5530	006	2	1	04	01	H5530_006_2	10	4	Diag/Rad	01	8a1;8b1;8b3;		2		2			2		1	35	35
H5530	006	2	1	04	01	H5530_006_2	10	5	PCP	01	7a;7g;		2		1	40.00	40.00	2		2		
H5530	006	2	1	04	01	H5530_006_2	10	6	SPEC	11	7b;7c;7d;7e;7f;7h;7i;	14b;	2		1	60.00	60.00	2		2		
H5530	804	0	1	04	01	H5530_804_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5530	804	0	1	04	01	H5530_804_0	4	1		01	6;14a;		2		2			2		1	0	0
H5530	805	0	1	04	01	H5530_805_0	4	1		01	6;14a;		2		2			2		1	0	0
H5530	805	0	1	04	01	H5530_805_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5530	806	0	1	04	01	H5530_806_0	4	1		01	6;14a;		2		2			2		1	0	0
H5530	806	0	1	04	01	H5530_806_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5530	808	0	2	04	01	H5530_808_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5530	808	0	2	04	01	H5530_808_0	4	1		01	6;14a;		2		2			2		1	0	0
H5533	003	0	1	04	01	H5533_003_0	9	2	$40 OON Copay	01	7a;		2		1	40.00	40.00	2		2		
H5533	003	0	1	04	01	H5533_003_0	9	1	30% Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;12;14a;14d;14e;16b;17a;17b;18a;	7b;7f;9d;14b;	2		2			2		1	30	30
H5533	003	0	1	04	01	H5533_003_0	9	3	$60 OON Copay	01	7d;7g;		2		1	60.00	60.00	2		2		
H5533	003	0	1	04	01	H5533_003_0	9	4	OON Routine Vision	10		17a;17b;	2		1	0.00	0.00	2		2		
H5533	003	0	1	04	01	H5533_003_0	9	5	50% OON	11	11a;11b;11c;15;	14c;16a;	2		2			2		1	50	50
H5533	005	0	1	04	01	H5533_005_0	9	4	50% OON	11	11a;11b;11c;	14c;16a;	2		2			2		1	50	50
H5533	005	0	1	04	01	H5533_005_0	9	3	$50 OON Copay	01	7d;7g;		2		1	50.00	50.00	2		2		
H5533	005	0	1	04	01	H5533_005_0	9	2	$30 OON Copay	01	7a;		2		1	30.00	30.00	2		2		
H5533	005	0	1	04	01	H5533_005_0	9	1	30% OON coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;12;14a;14d;14e;15;16b;17a;17b;18a;	7b;7f;9d;14b;18a;	2		2			2		1	30	30
H5533	005	0	1	04	01	H5533_005_0	9	5	OON Benefit Allowance	10		17a;17b;18b;	2		2			2		2		
H5533	006	0	1	04	01	H5533_006_0	9	1	30% Coinsurance	11	3-1;3-2;3-3;5;6;7b;7c;7e;7f;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;12;14a;14d;14e;16b;17a;17b;18a;	7b;7f;9d;14b;	2		2			2		1	30	30
H5533	006	0	1	04	01	H5533_006_0	9	2	$40 OON Copay	01	7a;		2		1	40.00	40.00	2		2		
H5533	006	0	1	04	01	H5533_006_0	9	3	$60 OON Copay	01	7d;7g;		2		1	60.00	60.00	2		2		
H5533	006	0	1	04	01	H5533_006_0	9	4	OON Routine Vision	10		17a;17b;	2		1	0.00	0.00	2		2		
H5533	006	0	1	04	01	H5533_006_0	9	5	50% OON	11	11a;11b;11c;15;	14c;16a;	2		2			2		1	50	50
H5533	801	0	1	04	01	H5533_801_0	3	1		01	6;14a;		2		2			2		1	0	0
H5533	801	0	1	04	01	H5533_801_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5533	802	0	1	04	01	H5533_802_0	3	1		01	6;14a;		2		2			2		1	0	0
H5533	802	0	1	04	01	H5533_802_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5533	803	0	1	04	01	H5533_803_0	4	1		01	6;14a;		2		2			2		1	0	0
H5533	803	0	1	04	01	H5533_803_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5970	001	0	1	04	01	H5970_001_0	3	7		10		13b;	1	20.00	2			2		1	50	50
H5970	001	0	1	04	01	H5970_001_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H5970	001	0	1	04	01	H5970_001_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5970	001	0	1	04	01	H5970_001_0	3	3		01	14a;		2		1	0.00	0.00	2		1	0	30
H5970	001	0	1	04	01	H5970_001_0	3	4		01	6;8b2;11a;11b;12;		2		2			2		1	20	20
H5970	001	0	1	04	01	H5970_001_0	3	5		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b3;9a;9b;9c;11c;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H5970	001	0	1	04	01	H5970_001_0	3	6		10		13c;14c;16a;16b;	2		2			2		1	50	50
H5970	002	0	1	04	01	H5970_002_0	3	7		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13c;13d;14b;14c;16a;16b;	2		2			2		1	50	50
H5970	002	0	1	04	01	H5970_002_0	3	6		10		18a;18b;	2		2			2		1	25	25
H5970	002	0	1	04	01	H5970_002_0	3	5		01	6;11a;		2		2			2		1	20	20
H5970	002	0	1	04	01	H5970_002_0	3	4		01	14a;		2		2			2		1	0	50
H5970	002	0	1	04	01	H5970_002_0	3	3		01	12;		2		2			2		1	0	20
H5970	002	0	1	04	01	H5970_002_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H5970	002	0	1	04	01	H5970_002_0	3	8		10		13b;	1	20.00	2			2		1	50	50
H5970	002	0	1	04	01	H5970_002_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H5970	004	0	1	04	01	H5970_004_0	3	8		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14e;15;16b;17a;18a;	13c;13d;14b;14c;16a;16b;	2		2			2		1	50	50
H5970	004	0	1	04	01	H5970_004_0	3	7		01	6;		2		2			2		1	35	35
H5970	004	0	1	04	01	H5970_004_0	3	6		10		18a;18b;	2		2			2		1	25	25
H5970	004	0	1	04	01	H5970_004_0	3	5		01	11a;12;		2		2			2		1	20	20
H5970	004	0	1	04	01	H5970_004_0	3	4		01	14a;		2		2			2		1	0	50
H5970	004	0	1	04	01	H5970_004_0	3	3		01	14d;		2		2			2		1	0	0
H5970	004	0	1	04	01	H5970_004_0	3	2		01	10a;		2		1	100.00	100.00	2		2		
H5970	004	0	1	04	01	H5970_004_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H5970	004	0	1	04	01	H5970_004_0	3	9		10		13b;	1	25.00	2			2		1	50	50
H5970	008	0	1	04	01	H5970_008_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H5970	008	0	1	04	01	H5970_008_0	3	10		01	3-1;3-2;3-3;7c;7i;8b1;9c;		2		1	60.00	60.00	2		1	20	20
H5970	008	0	1	04	01	H5970_008_0	3	9		11	8a1;8a2;8b3;14e;	13d;	2		1	20.00	60.00	2		1	20	20
H5970	008	0	1	04	01	H5970_008_0	3	8		01	5;6;8b2;9a;9b;11a;11b;11c;15;		2		2			2		1	20	20
H5970	008	0	1	04	01	H5970_008_0	3	7		01	14a;		2		1	20.00	60.00	2		1	0	20
H5970	008	0	1	04	01	H5970_008_0	3	6		01	12;		2		2			2		1	0	20
H5970	008	0	1	04	01	H5970_008_0	3	5		01	7b;7d;7e;7f;7g;7h;16b;17a;18a;		2		1	60.00	60.00	2		2		
H5970	008	0	1	04	01	H5970_008_0	3	4		01	10a;		2		1	300.00	300.00	2		2		
H5970	008	0	1	04	01	H5970_008_0	3	3		01	14d;		2		1	20.00	60.00	2		2		
H5970	008	0	1	04	01	H5970_008_0	3	2		11	7a;	14b;	2		1	20.00	20.00	2		2		
H5970	008	0	1	04	01	H5970_008_0	3	12		10		13b;	1	15.00	2			2		1	50	50
H5970	008	0	1	04	01	H5970_008_0	3	11		10		13c;14c;	2		2			2		1	50	50
H5970	801	0	1	04	01	H5970_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5970	801	0	1	04	01	H5970_801_0	1	1		01	6;14a;		2		2			2		1	0	0
H5970	802	0	1	04	01	H5970_802_0	1	1		01	6;14a;		2		2			2		1	0	0
H5970	802	0	1	04	01	H5970_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5970	803	0	1	04	01	H5970_803_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5970	803	0	1	04	01	H5970_803_0	1	1		01	6;14a;		2		2			2		1	0	0
H5970	805	0	2	04	01	H5970_805_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5970	805	0	2	04	01	H5970_805_0	1	1		01	6;14a;		2		2			2		1	0	0
H5970	806	0	2	04	01	H5970_806_0	1	1		01	6;14a;		2		2			2		1	0	0
H5970	806	0	2	04	01	H5970_806_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H5970	807	0	2	04	01	H5970_807_0	1	1		01	6;14a;		2		2			2		1	0	0
H5970	807	0	2	04	01	H5970_807_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H6328	001	0	1	04	01	H6328_001_0	5	5	$50 Copay	01	7e;7h;9c;12;		2		1	50.00	50.00	2		2		
H6328	001	0	1	04	01	H6328_001_0	5	4	$40 Copay	01	6;		2		1	40.00	40.00	2		2		
H6328	001	0	1	04	01	H6328_001_0	5	7	$150 Copay	01	9b;		2		1	150.00	150.00	2		2		
H6328	001	0	1	04	01	H6328_001_0	5	8	$200 Copay	01	9a;		2		1	200.00	200.00	2		2		
H6328	001	0	1	04	01	H6328_001_0	5	9	$10 to $25 Copay	01	8a1;8a2;8b3;		2		1	10.00	25.00	2		2		
H6328	001	0	1	04	01	H6328_001_0	5	1	$20 Copay	01	3-1;3-2;3-3;7b;		2		1	20.00	20.00	2		2		
H6328	001	0	1	04	01	H6328_001_0	5	10	$75 to $200 Copay	01	8b1;		2		1	75.00	200.00	2		2		
H6328	001	0	1	04	01	H6328_001_0	5	11	20% Coinsurance	01	11c;14d;14e;		2		2			2		1	20	20
H6328	001	0	1	04	01	H6328_001_0	5	12	30% Coinsurance	01	8b2;9d;11a;11b;15;		2		2			2		1	30	30
H6328	001	0	1	04	01	H6328_001_0	5	13	50% Coinsurance	01	17b;		2		2			2		1	50	50
H6328	001	0	1	04	01	H6328_001_0	5	14	50% Coinsurance	10		17b;	2		2			2		1	50	50
H6328	001	0	1	04	01	H6328_001_0	5	15	$25 Copay	01	7c;7i;		2		1	25.00	25.00	2		2		
H6328	001	0	1	04	01	H6328_001_0	5	2	$30 Copay	11	7a;14a;	10b;14c;	2		1	30.00	30.00	2		2		
H6328	001	0	1	04	01	H6328_001_0	5	3	$35 Copay	11	7d;7f;7g;16b;17a;18a;	16a;17a;18a;	2		1	35.00	35.00	2		2		
H6328	001	0	1	04	01	H6328_001_0	5	6	$100 Copay	01	5;10a;		2		1	100.00	100.00	2		2		
H6328	002	0	1	04	01	H6328_002_0	7	2	$30 Copay	11	7a;14a;	10b;14c;	2		1	30.00	30.00	2		2		
H6328	002	0	1	04	01	H6328_002_0	7	3	$40 Copay	11	6;7d;7f;7g;16b;17a;18a;	17a;	2		1	40.00	40.00	2		2		
H6328	002	0	1	04	01	H6328_002_0	7	4	$55 Copay	01	7e;7h;9c;12;		2		1	55.00	55.00	2		2		
H6328	002	0	1	04	01	H6328_002_0	7	5	$100 Copay	01	10a;		2		1	100.00	100.00	2		2		
H6328	002	0	1	04	01	H6328_002_0	7	1	$20 Copay	01	3-1;3-2;3-3;7b;		2		1	20.00	20.00	2		2		
H6328	002	0	1	04	01	H6328_002_0	7	6	$125 Copay	01	5;		2		1	125.00	125.00	2		2		
H6328	002	0	1	04	01	H6328_002_0	7	7	$175 Copay	01	9b;		2		1	175.00	175.00	2		2		
H6328	002	0	1	04	01	H6328_002_0	7	8	$225 Copay	01	9a;		2		1	225.00	225.00	2		2		
H6328	002	0	1	04	01	H6328_002_0	7	9	$10 to $25 Copay	01	8a1;8a2;8b3;		2		1	10.00	25.00	2		2		
H6328	002	0	1	04	01	H6328_002_0	7	10	$75 to $200 Copay	01	8b1;		2		1	75.00	200.00	2		2		
H6328	002	0	1	04	01	H6328_002_0	7	11	20% Coinsurance	01	11c;14d;14e;		2		2			2		1	20	20
H6328	002	0	1	04	01	H6328_002_0	7	12	30% Coinsurance	01	8b2;9d;11a;11b;15;		2		2			2		1	30	30
H6328	002	0	1	04	01	H6328_002_0	7	13	50% Coinsurance	01	17b;		2		2			2		1	50	50
H6328	002	0	1	04	01	H6328_002_0	7	14	50% Coinsurance	10		17b;	2		2			2		1	50	50
H6328	002	0	1	04	01	H6328_002_0	7	15	$35 Copay	01	7c;7i;		2		1	35.00	35.00	2		2		
H6328	003	0	1	04	01	H6328_003_0	6	11	$10 to $25 Copay	01	8a1;8a2;8b3;		2		1	10.00	25.00	2		2		
H6328	003	0	1	04	01	H6328_003_0	6	9	$200 Copay	01	9b;10a;		2		1	200.00	200.00	2		2		
H6328	003	0	1	04	01	H6328_003_0	6	1	$20 copay	01	7b;		2		1	20.00	20.00	2		2		
H6328	003	0	1	04	01	H6328_003_0	6	12	$75 to $250 Copay	01	8b1;		2		1	75.00	250.00	2		2		
H6328	003	0	1	04	01	H6328_003_0	6	13	20% Coinsurance	01	11c;14d;14e;		2		2			2		1	20	20
H6328	003	0	1	04	01	H6328_003_0	6	14	30% Coinsurance	01	8b2;9d;11a;11b;15;		2		2			2		1	30	30
H6328	003	0	1	04	01	H6328_003_0	6	15	50% Coinsurance	01	17b;		2		2			2		1	50	50
H6328	003	0	1	04	01	H6328_003_0	6	2	$25 copay	01	3-1;3-2;3-3;		2		1	25.00	25.00	2		2		
H6328	003	0	1	04	01	H6328_003_0	6	3	$30 copay	11	14a;	10b;14c;	2		1	30.00	30.00	2		2		
H6328	003	0	1	04	01	H6328_003_0	6	4	$40 copay	01	7c;7i;		2		1	40.00	40.00	2		2		
H6328	003	0	1	04	01	H6328_003_0	6	5	$45 Copay	01	6;7a;		2		1	45.00	45.00	2		2		
H6328	003	0	1	04	01	H6328_003_0	6	6	$50 Copay	01	7d;7f;7g;16b;17a;18a;		2		1	50.00	50.00	2		2		
H6328	003	0	1	04	01	H6328_003_0	6	7	$60 Copay	01	7e;7h;9c;12;		2		1	60.00	60.00	2		2		
H6328	003	0	1	04	01	H6328_003_0	6	8	$150 Copay	01	5;		2		1	150.00	150.00	2		2		
H6328	003	0	1	04	01	H6328_003_0	6	10	$250 Copay	01	9a;		2		1	250.00	250.00	2		2		
H6328	005	0	1	04	01	H6328_005_0	5	11	20% Coinsurance	01	11a;11b;11c;14d;14e;15;		2		2			2		1	20	20
H6328	005	0	1	04	01	H6328_005_0	5	10	$75 to $200 Copay	01	8b1;		2		1	75.00	200.00	2		2		
H6328	005	0	1	04	01	H6328_005_0	5	1	$20 Copay	01	3-1;3-2;3-3;7b;7c;7i;		2		1	20.00	20.00	2		2		
H6328	005	0	1	04	01	H6328_005_0	5	12	30% Coinsurance	01	8b2;9d;		2		2			2		1	30	30
H6328	005	0	1	04	01	H6328_005_0	5	9	$10 to $25 Copay	01	8a1;8a2;8b3;		2		1	10.00	25.00	2		2		
H6328	005	0	1	04	01	H6328_005_0	5	8	$200 Copay	01	9a;		2		1	200.00	200.00	2		2		
H6328	005	0	1	04	01	H6328_005_0	5	7	$150 Copay	01	9b;		2		1	150.00	150.00	2		2		
H6328	005	0	1	04	01	H6328_005_0	5	6	$100 Copay	01	5;10a;		2		1	100.00	100.00	2		2		
H6328	005	0	1	04	01	H6328_005_0	5	5	$50 Copay	01	7e;7h;9c;12;		2		1	50.00	50.00	2		2		
H6328	005	0	1	04	01	H6328_005_0	5	4	$40 Copay	01	6;		2		1	40.00	40.00	2		2		
H6328	005	0	1	04	01	H6328_005_0	5	3	$35 Copay	11	7f;7g;16b;17a;18a;	16a;17a;18a;	2		1	35.00	35.00	2		2		
H6328	005	0	1	04	01	H6328_005_0	5	13	50% Coinsurance	01	17b;		2		2			2		1	50	50
H6328	005	0	1	04	01	H6328_005_0	5	14	50% Coinsurance	10		17b;18b;	2		2			2		1	50	50
H6328	005	0	1	04	01	H6328_005_0	5	15	$25 Copay	01	7a;		2		1	25.00	25.00	2		2		
H6328	005	0	1	04	01	H6328_005_0	5	2	$30 Copay	11	7d;14a;	10b;14c;	2		1	30.00	30.00	2		2		
H6328	801	0	1	04	01	H6328_801_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H6328	801	0	1	04	01	H6328_801_0	6	1		01	6;14a;		2		2			2		1	0	0
H6328	802	0	1	04	01	H6328_802_0	6	1		01	6;14a;		2		2			2		1	0	0
H6328	802	0	1	04	01	H6328_802_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H6328	803	0	1	04	01	H6328_803_0	7	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H6328	803	0	1	04	01	H6328_803_0	7	1		01	6;14a;		2		2			2		1	0	0
H6328	804	0	1	04	01	H6328_804_0	7	1		01	6;14a;		2		2			2		1	0	0
H6328	804	0	1	04	01	H6328_804_0	7	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H6528	006	0	1	04	01	H6528_006_0	2	7	Group 7	01	8a2;		2		1	18.00	18.00	2		2		
H6528	006	0	1	04	01	H6528_006_0	2	11	Group 11	11	9d;14a;14d;14e;17b;	9d;14b;14c;16b;17b;	2		1	0.00	0.00	2		2		
H6528	006	0	1	04	01	H6528_006_0	2	9	Group 9	11	7b;	16a;	2		1	20.00	20.00	2		2		
H6528	006	0	1	04	01	H6528_006_0	2	2	Group 2	01	5;		2		1	55.00	55.00	2		2		
H6528	006	0	1	04	01	H6528_006_0	2	15	Group 15	01	8b3;		2		1	16.00	16.00	2		2		
H6528	006	0	1	04	01	H6528_006_0	2	14	Group 14	01	7g;		2		1	10.00	30.00	2		2		
H6528	006	0	1	04	01	H6528_006_0	2	13	Group 13	10		18b;	2		1	390.00	450.00	2		2		
H6528	006	0	1	04	01	H6528_006_0	2	12	Group 12	01	10a;		2		1	250.00	250.00	2		2		
H6528	006	0	1	04	01	H6528_006_0	2	3	Group 3	01	6;11a;		2		2			2		1	50	50
H6528	006	0	1	04	01	H6528_006_0	2	4	Group 4	11	7a;18a;	18a;	2		1	10.00	10.00	2		2		
H6528	006	0	1	04	01	H6528_006_0	2	5	Group 5	01	17a;		2		1	0.00	30.00	2		2		
H6528	006	0	1	04	01	H6528_006_0	2	6	Group 6	01	7e;7h;9c;		2		1	30.00	40.00	2		2		
H6528	006	0	1	04	01	H6528_006_0	2	1	Group 1	11	3-1;3-2;3-3;7c;7d;7f;7i;16b;	7f;	2		1	30.00	30.00	2		2		
H6528	006	0	1	04	01	H6528_006_0	2	10	Group 10	10		17a;	2		1	25.00	25.00	2		2		
H6528	006	0	1	04	01	H6528_006_0	2	8	Group 8	01	8a1;8b1;8b2;9a;9b;11b;11c;12;15;		2		2			2		1	20	20
H6528	016	0	1	04	01	H6528_016_0	2	9	Group 9	01	8a1;8a2;8b1;8b2;8b3;		2		1	16.00	18.00	2		1	20	20
H6528	016	0	1	04	01	H6528_016_0	2	8	Group 8	01	9a;9b;11b;11c;12;15;		2		2			2		1	20	20
H6528	016	0	1	04	01	H6528_016_0	2	7	Group 7	11	7a;18a;	18a;	2		1	15.00	15.00	2		2		
H6528	016	0	1	04	01	H6528_016_0	2	6	Group 6	01	7e;7h;9c;		2		1	30.00	40.00	2		2		
H6528	016	0	1	04	01	H6528_016_0	2	5	Group 5	11	7b;	16a;	2		1	20.00	20.00	2		2		
H6528	016	0	1	04	01	H6528_016_0	2	4	Group 4	01	7c;7i;		2		1	40.00	40.00	2		2		
H6528	016	0	1	04	01	H6528_016_0	2	3	Group 3	01	6;11a;		2		2			2		1	50	50
H6528	016	0	1	04	01	H6528_016_0	2	2	Group 2	01	5;		2		1	55.00	55.00	2		2		
H6528	016	0	1	04	01	H6528_016_0	2	14	Group 14	01	7g;		2		1	15.00	45.00	2		2		
H6528	016	0	1	04	01	H6528_016_0	2	15	Group 15	10		17a;	2		1	25.00	25.00	2		2		
H6528	016	0	1	04	01	H6528_016_0	2	13	Group 13	01	10a;		2		1	250.00	250.00	2		2		
H6528	016	0	1	04	01	H6528_016_0	2	12	Group 12	01	17a;		2		1	0.00	45.00	2		2		
H6528	016	0	1	04	01	H6528_016_0	2	11	Group 11	11	7f;9d;14a;14d;14e;17b;	7f;9d;10b;14c;16b;17b;	2		1	0.00	0.00	2		2		
H6528	016	0	1	04	01	H6528_016_0	2	10	Group 10	10		18b;	2		1	390.00	450.00	2		2		
H6528	016	0	1	04	01	H6528_016_0	2	1	Group 1	01	3-1;3-2;3-3;7d;16b;		2		1	45.00	45.00	2		2		
H6528	029	0	1	04	01	H6528_029_0	2	5	Group 5	01	17a;		2		1	0.00	50.00	2		2		
H6528	029	0	1	04	01	H6528_029_0	2	12	Group 12	10		18b;	2		1	390.00	450.00	2		2		
H6528	029	0	1	04	01	H6528_029_0	2	7	Group 7	10		17a;	2		1	25.00	25.00	2		2		
H6528	029	0	1	04	01	H6528_029_0	2	8	Group 8	01	8a1;8b1;8b2;9a;9b;11b;11c;12;15;		2		2			2		1	20	20
H6528	029	0	1	04	01	H6528_029_0	2	9	Group 9	01	8a2;		2		1	18.00	18.00	2		2		
H6528	029	0	1	04	01	H6528_029_0	2	6	Group 6	01	7e;7h;9c;		2		1	30.00	40.00	2		2		
H6528	029	0	1	04	01	H6528_029_0	2	13	Group 13	01	10a;		2		1	250.00	250.00	2		2		
H6528	029	0	1	04	01	H6528_029_0	2	14	Group 14	01	7g;		2		1	20.00	50.00	2		2		
H6528	029	0	1	04	01	H6528_029_0	2	15	Group 15	01	8b3;		2		1	16.00	16.00	2		2		
H6528	029	0	1	04	01	H6528_029_0	2	2	Group 2	01	6;11a;		2		2			2		1	50	50
H6528	029	0	1	04	01	H6528_029_0	2	3	Group 3	01	5;		2		1	55.00	55.00	2		2		
H6528	029	0	1	04	01	H6528_029_0	2	4	Group 4	11	7a;7b;18a;	16a;18a;	2		1	20.00	20.00	2		2		
H6528	029	0	1	04	01	H6528_029_0	2	1	Group 1	01	3-1;3-2;3-3;7d;16b;		2		1	50.00	50.00	2		2		
H6528	029	0	1	04	01	H6528_029_0	2	10	Group 10	01	7c;7i;		2		1	40.00	40.00	2		2		
H6528	029	0	1	04	01	H6528_029_0	2	11	Group 11	11	7f;9d;14a;14d;14e;17b;	7f;9d;10b;14c;16b;17b;	2		1	0.00	0.00	2		2		
H6528	030	0	1	04	01	H6528_030_0	2	5	Group 5	01	17a;		2		1	0.00	50.00	2		2		
H6528	030	0	1	04	01	H6528_030_0	2	1	Group 1	11	3-1;3-2;3-3;7d;7f;16b;	7f;	2		1	50.00	50.00	2		2		
H6528	030	0	1	04	01	H6528_030_0	2	7	Group 7	11	7b;18a;	16a;18a;	2		1	20.00	20.00	2		2		
H6528	030	0	1	04	01	H6528_030_0	2	8	Group 8	01	9a;9b;11b;11c;12;15;		2		2			2		1	20	20
H6528	030	0	1	04	01	H6528_030_0	2	9	Group 9	01	8a1;8a2;8b1;8b2;8b3;		2		1	16.00	19.00	2		1	20	20
H6528	030	0	1	04	01	H6528_030_0	2	4	Group 4	11	7a;	17a;	2		1	25.00	25.00	2		2		
H6528	030	0	1	04	01	H6528_030_0	2	3	Group 3	01	5;		2		1	55.00	55.00	2		2		
H6528	030	0	1	04	01	H6528_030_0	2	2	Group 2	01	6;		2		2			2		1	50	50
H6528	030	0	1	04	01	H6528_030_0	2	15	Group 15	01	11a;		2		2			2		1	45	45
H6528	030	0	1	04	01	H6528_030_0	2	14	Group 14	01	7g;		2		1	25.00	50.00	2		2		
H6528	030	0	1	04	01	H6528_030_0	2	13	Group 13	01	10a;		2		1	250.00	250.00	2		2		
H6528	030	0	1	04	01	H6528_030_0	2	12	Group 12	10		18b;	2		1	390.00	450.00	2		2		
H6528	030	0	1	04	01	H6528_030_0	2	11	Group 11	11	9d;14a;14d;14e;17b;	9d;14b;14c;16b;17b;	2		1	0.00	0.00	2		2		
H6528	030	0	1	04	01	H6528_030_0	2	10	Group 10	01	7c;7i;		2		1	40.00	40.00	2		2		
H6528	030	0	1	04	01	H6528_030_0	2	6	Group 6	01	7e;7h;9c;		2		1	30.00	40.00	2		2		
H6609	001	0	1	04	01	H6609_001_0	4	4		01	11a;		2		2			2		1	15	15
H6609	001	0	1	04	01	H6609_001_0	4	3		01	14a;		2		2			2		1	0	50
H6609	001	0	1	04	01	H6609_001_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	001	0	1	04	01	H6609_001_0	4	1		11	9d;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	001	0	1	04	01	H6609_001_0	4	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;13d;14b;14c;16a;	2		2			2		1	50	50
H6609	001	0	1	04	01	H6609_001_0	4	7		10		13b;	1	20.00	2			2		1	50	50
H6609	001	0	1	04	01	H6609_001_0	4	5		01	12;		2		2			2		1	20	20
H6609	001	0	1	04	01	H6609_001_0	4	8		10		16b;	2		2			2		1	50	75
H6609	003	0	1	04	01	H6609_003_0	3	4		01	11a;		2		2			2		1	18	18
H6609	003	0	1	04	01	H6609_003_0	3	5		01	12;		2		2			2		1	20	20
H6609	003	0	1	04	01	H6609_003_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;13d;14b;14c;	2		2			2		1	50	50
H6609	003	0	1	04	01	H6609_003_0	3	7		10		13b;	1	10.00	2			2		1	50	50
H6609	003	0	1	04	01	H6609_003_0	3	1		11	9d;	9d;	2		1	0.00	0.00	2		2		
H6609	003	0	1	04	01	H6609_003_0	3	3		01	14a;		2		2			2		1	0	50
H6609	003	0	1	04	01	H6609_003_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	004	0	1	04	01	H6609_004_0	3	5		01	12;		2		2			2		1	20	20
H6609	004	0	1	04	01	H6609_004_0	3	4		01	11a;		2		2			2		1	10	10
H6609	004	0	1	04	01	H6609_004_0	3	3		01	14a;		2		2			2		1	0	50
H6609	004	0	1	04	01	H6609_004_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	004	0	1	04	01	H6609_004_0	3	8		10		13b;	1	20.00	2			2		1	50	50
H6609	004	0	1	04	01	H6609_004_0	3	6		01	11c;		2		2			2		1	20	50
H6609	004	0	1	04	01	H6609_004_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;15;16b;17a;17b;18a;	13c;13d;14b;14c;	2		2			2		1	50	50
H6609	004	0	1	04	01	H6609_004_0	3	1		11	9d;	9d;	2		1	0.00	0.00	2		2		
H6609	009	0	1	04	01	H6609_009_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	009	0	1	04	01	H6609_009_0	3	7		10		13b;	1	15.00	2			2		1	50	50
H6609	009	0	1	04	01	H6609_009_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13c;13d;14b;14c;	2		2			2		1	50	50
H6609	009	0	1	04	01	H6609_009_0	3	4		01	12;		2		2			2		1	20	20
H6609	009	0	1	04	01	H6609_009_0	3	5		01	11a;		2		2			2		1	30	30
H6609	009	0	1	04	01	H6609_009_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	009	0	1	04	01	H6609_009_0	3	3		01	14a;		2		2			2		1	0	50
H6609	012	0	1	04	01	H6609_012_0	2	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	012	0	1	04	01	H6609_012_0	2	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	012	0	1	04	01	H6609_012_0	2	3		01	14a;		2		2			2		1	0	50
H6609	012	0	1	04	01	H6609_012_0	2	4		01	12;		2		2			2		1	20	20
H6609	012	0	1	04	01	H6609_012_0	2	5		01	11a;		2		2			2		1	30	30
H6609	012	0	1	04	01	H6609_012_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13c;13d;14b;14c;	2		2			2		1	50	50
H6609	012	0	1	04	01	H6609_012_0	2	7		10		13b;	1	15.00	2			2		1	50	50
H6609	013	0	1	04	01	H6609_013_0	3	1		11	9d;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	013	0	1	04	01	H6609_013_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	013	0	1	04	01	H6609_013_0	3	3		01	14a;		2		2			2		1	0	50
H6609	013	0	1	04	01	H6609_013_0	3	4		01	12;		2		2			2		1	20	20
H6609	013	0	1	04	01	H6609_013_0	3	5		01	11a;		2		2			2		1	28	28
H6609	013	0	1	04	01	H6609_013_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;13d;14b;14c;	2		2			2		1	50	50
H6609	013	0	1	04	01	H6609_013_0	3	7		10		13b;	1	15.00	2			2		1	50	50
H6609	017	0	1	04	01	H6609_017_0	3	1		11	9d;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	017	0	1	04	01	H6609_017_0	3	7		10		16b;	2		2			2		1	50	55
H6609	017	0	1	04	01	H6609_017_0	3	6		10		13b;	1	20.00	2			2		1	50	50
H6609	017	0	1	04	01	H6609_017_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;13d;14b;14c;16a;	2		2			2		1	50	50
H6609	017	0	1	04	01	H6609_017_0	3	4		01	11a;12;		2		2			2		1	20	20
H6609	017	0	1	04	01	H6609_017_0	3	3		01	14a;		2		2			2		1	0	50
H6609	017	0	1	04	01	H6609_017_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	019	0	1	04	01	H6609_019_0	3	1		11	9d;	9d;	2		1	0.00	0.00	2		2		
H6609	019	0	1	04	01	H6609_019_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	019	0	1	04	01	H6609_019_0	3	8		10		13b;	1	20.00	2			2		1	50	50
H6609	019	0	1	04	01	H6609_019_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;15;16b;17a;17b;18a;	13c;13d;14b;14c;16a;	2		2			2		1	50	50
H6609	019	0	1	04	01	H6609_019_0	3	9		10		16b;	2		2			2		1	50	55
H6609	019	0	1	04	01	H6609_019_0	3	5		01	12;		2		2			2		1	20	20
H6609	019	0	1	04	01	H6609_019_0	3	4		01	11a;		2		2			2		1	15	15
H6609	019	0	1	04	01	H6609_019_0	3	3		01	14a;		2		2			2		1	0	50
H6609	019	0	1	04	01	H6609_019_0	3	6		01	11c;		2		2			2		1	20	50
H6609	029	0	1	04	01	H6609_029_0	3	1		11	9d;	9d;	2		1	0.00	0.00	2		2		
H6609	029	0	1	04	01	H6609_029_0	3	2		01	10a;		2		1	325.00	325.00	2		2		
H6609	029	0	1	04	01	H6609_029_0	3	6		10		13b;	1	10.00	2			2		1	50	50
H6609	029	0	1	04	01	H6609_029_0	3	4		01	11a;12;		2		2			2		1	20	20
H6609	029	0	1	04	01	H6609_029_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;13d;14b;14c;	2		2			2		1	50	50
H6609	029	0	1	04	01	H6609_029_0	3	3		01	14a;		2		2			2		1	0	50
H6609	073	0	1	04	01	H6609_073_0	3	1		11	9d;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	073	0	1	04	01	H6609_073_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	073	0	1	04	01	H6609_073_0	3	3		01	14a;		2		2			2		1	0	30
H6609	073	0	1	04	01	H6609_073_0	3	8		10		16b;	2		2			2		1	50	55
H6609	073	0	1	04	01	H6609_073_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;16b;17a;17b;18a;	13d;14b;	2		2			2		1	30	30
H6609	073	0	1	04	01	H6609_073_0	3	6		10		13c;14c;16a;	2		2			2		1	50	50
H6609	073	0	1	04	01	H6609_073_0	3	7		10		13b;	1	15.00	2			2		1	50	50
H6609	073	0	1	04	01	H6609_073_0	3	4		01	12;15;		2		2			2		1	20	20
H6609	075	0	1	04	01	H6609_075_0	3	7		10		13b;	1	10.00	2			2		1	50	50
H6609	075	0	1	04	01	H6609_075_0	3	1		11	9d;	9d;	2		1	0.00	0.00	2		2		
H6609	075	0	1	04	01	H6609_075_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	075	0	1	04	01	H6609_075_0	3	3		01	14a;		2		2			2		1	0	50
H6609	075	0	1	04	01	H6609_075_0	3	4		01	15;		2		2			2		1	15	15
H6609	075	0	1	04	01	H6609_075_0	3	5		01	11a;12;		2		2			2		1	20	20
H6609	075	0	1	04	01	H6609_075_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;17b;18a;	13c;13d;14b;14c;	2		2			2		1	50	50
H6609	077	0	1	04	01	H6609_077_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	077	0	1	04	01	H6609_077_0	3	3		01	12;		2		2			2		1	0	20
H6609	077	0	1	04	01	H6609_077_0	3	9		10		13c;14c;16a;	2		2			2		1	50	50
H6609	077	0	1	04	01	H6609_077_0	3	8		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	077	0	1	04	01	H6609_077_0	3	11		10		16b;	2		2			2		1	50	55
H6609	077	0	1	04	01	H6609_077_0	3	10		10		13b;	1	20.00	2			2		1	50	50
H6609	077	0	1	04	01	H6609_077_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	077	0	1	04	01	H6609_077_0	3	7		10		18a;18b;	2		2			2		1	25	25
H6609	077	0	1	04	01	H6609_077_0	3	6		01	15;		2		2			2		1	20	30
H6609	077	0	1	04	01	H6609_077_0	3	5		01	11a;		2		2			2		1	20	20
H6609	077	0	1	04	01	H6609_077_0	3	4		01	14a;		2		2			2		1	0	30
H6609	078	0	1	04	01	H6609_078_0	4	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	078	0	1	04	01	H6609_078_0	4	6		01	15;		2		2			2		1	20	30
H6609	078	0	1	04	01	H6609_078_0	4	5		01	11a;		2		2			2		1	20	20
H6609	078	0	1	04	01	H6609_078_0	4	4		01	14a;		2		2			2		1	0	30
H6609	078	0	1	04	01	H6609_078_0	4	9		10		13b;	1	20.00	2			2		1	50	50
H6609	078	0	1	04	01	H6609_078_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	078	0	1	04	01	H6609_078_0	4	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	078	0	1	04	01	H6609_078_0	4	8		10		13c;14c;16a;16b;	2		2			2		1	50	50
H6609	078	0	1	04	01	H6609_078_0	4	3		01	12;		2		2			2		1	0	20
H6609	080	0	1	04	01	H6609_080_0	4	9		10		13b;	1	20.00	2			2		1	50	50
H6609	080	0	1	04	01	H6609_080_0	4	8		10		13c;14c;16a;16b;	2		2			2		1	50	50
H6609	080	0	1	04	01	H6609_080_0	4	7		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	080	0	1	04	01	H6609_080_0	4	6		01	8a1;15;		2		2			2		1	20	30
H6609	080	0	1	04	01	H6609_080_0	4	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	080	0	1	04	01	H6609_080_0	4	4		01	14a;		2		2			2		1	0	30
H6609	080	0	1	04	01	H6609_080_0	4	3		01	12;		2		2			2		1	0	20
H6609	080	0	1	04	01	H6609_080_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	080	0	1	04	01	H6609_080_0	4	5		01	6;11a;11b;11c;		2		2			2		1	20	20
H6609	081	0	1	04	01	H6609_081_0	4	8		10		13c;14c;16a;	2		2			2		1	50	50
H6609	081	0	1	04	01	H6609_081_0	4	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	081	0	1	04	01	H6609_081_0	4	6		01	11a;		2		2			2		1	23	23
H6609	081	0	1	04	01	H6609_081_0	4	5		01	15;		2		2			2		1	20	30
H6609	081	0	1	04	01	H6609_081_0	4	4		01	14a;		2		2			2		1	0	30
H6609	081	0	1	04	01	H6609_081_0	4	3		01	12;		2		2			2		1	0	20
H6609	081	0	1	04	01	H6609_081_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	081	0	1	04	01	H6609_081_0	4	10		10		16b;	2		2			2		1	50	80
H6609	081	0	1	04	01	H6609_081_0	4	9		10		13b;	1	15.00	2			2		1	50	50
H6609	081	0	1	04	01	H6609_081_0	4	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	082	0	1	04	01	H6609_082_0	4	4		01	14a;		2		2			2		1	0	30
H6609	082	0	1	04	01	H6609_082_0	4	5		01	6;11a;11b;11c;		2		2			2		1	20	20
H6609	082	0	1	04	01	H6609_082_0	4	6		01	8a1;15;		2		2			2		1	20	30
H6609	082	0	1	04	01	H6609_082_0	4	7		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	082	0	1	04	01	H6609_082_0	4	8		10		13c;14c;16a;	2		2			2		1	50	50
H6609	082	0	1	04	01	H6609_082_0	4	9		10		13b;	1	15.00	2			2		1	50	50
H6609	082	0	1	04	01	H6609_082_0	4	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	082	0	1	04	01	H6609_082_0	4	10		10		16b;	2		2			2		1	50	80
H6609	082	0	1	04	01	H6609_082_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	082	0	1	04	01	H6609_082_0	4	3		01	12;		2		2			2		1	0	20
H6609	083	0	1	04	01	H6609_083_0	4	7		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	083	0	1	04	01	H6609_083_0	4	6		01	8a1;15;		2		2			2		1	20	30
H6609	083	0	1	04	01	H6609_083_0	4	9		10		13b;	1	15.00	2			2		1	50	50
H6609	083	0	1	04	01	H6609_083_0	4	8		10		13c;14c;16a;	2		2			2		1	50	50
H6609	083	0	1	04	01	H6609_083_0	4	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	083	0	1	04	01	H6609_083_0	4	10		10		16b;	2		2			2		1	50	80
H6609	083	0	1	04	01	H6609_083_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	083	0	1	04	01	H6609_083_0	4	3		01	12;		2		2			2		1	0	20
H6609	083	0	1	04	01	H6609_083_0	4	4		01	14a;		2		2			2		1	0	30
H6609	083	0	1	04	01	H6609_083_0	4	5		01	6;11a;11b;11c;		2		2			2		1	20	20
H6609	084	0	1	04	01	H6609_084_0	3	8		10		13c;14c;	2		2			2		1	50	50
H6609	084	0	1	04	01	H6609_084_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	084	0	1	04	01	H6609_084_0	3	6		01	15;		2		2			2		1	20	30
H6609	084	0	1	04	01	H6609_084_0	3	5		01	11a;		2		2			2		1	20	20
H6609	084	0	1	04	01	H6609_084_0	3	9		10		13b;	1	15.00	2			2		1	50	50
H6609	084	0	1	04	01	H6609_084_0	3	3		01	12;		2		2			2		1	0	20
H6609	084	0	1	04	01	H6609_084_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	084	0	1	04	01	H6609_084_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	084	0	1	04	01	H6609_084_0	3	4		01	14a;		2		2			2		1	0	30
H6609	085	0	1	04	01	H6609_085_0	4	8		10		13c;14c;16a;16b;	2		2			2		1	50	50
H6609	085	0	1	04	01	H6609_085_0	4	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	085	0	1	04	01	H6609_085_0	4	6		01	15;		2		2			2		1	20	30
H6609	085	0	1	04	01	H6609_085_0	4	5		01	11a;		2		2			2		1	20	20
H6609	085	0	1	04	01	H6609_085_0	4	4		01	14a;		2		2			2		1	0	30
H6609	085	0	1	04	01	H6609_085_0	4	3		01	12;		2		2			2		1	0	20
H6609	085	0	1	04	01	H6609_085_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	085	0	1	04	01	H6609_085_0	4	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	085	0	1	04	01	H6609_085_0	4	9		10		13b;	1	15.00	2			2		1	50	50
H6609	086	0	1	04	01	H6609_086_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	086	0	1	04	01	H6609_086_0	4	10		10		16b;	2		2			2		1	50	80
H6609	086	0	1	04	01	H6609_086_0	4	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	086	0	1	04	01	H6609_086_0	4	3		01	12;		2		2			2		1	0	20
H6609	086	0	1	04	01	H6609_086_0	4	9		10		13b;	1	15.00	2			2		1	50	50
H6609	086	0	1	04	01	H6609_086_0	4	5		01	6;11a;11b;		2		2			2		1	20	20
H6609	086	0	1	04	01	H6609_086_0	4	6		01	8a1;15;		2		2			2		1	20	30
H6609	086	0	1	04	01	H6609_086_0	4	7		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;8b1;8b2;8b3;9a;9b;9c;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	086	0	1	04	01	H6609_086_0	4	8		10		13c;14c;16a;	2		2			2		1	50	50
H6609	086	0	1	04	01	H6609_086_0	4	4		01	14a;		2		2			2		1	0	30
H6609	088	0	1	04	01	H6609_088_0	3	3		01	14a;		2		2			2		1	0	30
H6609	088	0	1	04	01	H6609_088_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	088	0	1	04	01	H6609_088_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	088	0	1	04	01	H6609_088_0	3	4		01	11a;11c;12;		2		2			2		1	20	20
H6609	088	0	1	04	01	H6609_088_0	3	8		10		13b;	1	10.00	2			2		1	50	50
H6609	088	0	1	04	01	H6609_088_0	3	7		10		13c;14c;	2		2			2		1	50	50
H6609	088	0	1	04	01	H6609_088_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	088	0	1	04	01	H6609_088_0	3	5		01	15;		2		2			2		1	20	30
H6609	089	0	1	04	01	H6609_089_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	089	0	1	04	01	H6609_089_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	089	0	1	04	01	H6609_089_0	3	3		01	14a;		2		2			2		1	0	40
H6609	089	0	1	04	01	H6609_089_0	3	4		01	11a;11c;12;		2		2			2		1	20	20
H6609	089	0	1	04	01	H6609_089_0	3	9		10		13b;	1	10.00	2			2		1	50	50
H6609	089	0	1	04	01	H6609_089_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	40	40
H6609	089	0	1	04	01	H6609_089_0	3	6		01	11b;		2		2			2		1	25	25
H6609	089	0	1	04	01	H6609_089_0	3	5		01	15;		2		2			2		1	20	40
H6609	089	0	1	04	01	H6609_089_0	3	8		10		13c;14c;	2		2			2		1	50	50
H6609	090	0	1	04	01	H6609_090_0	3	6		01	11a;11b;11c;		2		2			2		1	25	25
H6609	090	0	1	04	01	H6609_090_0	3	5		01	15;		2		2			2		1	20	30
H6609	090	0	1	04	01	H6609_090_0	3	8		10		13c;14c;	2		2			2		1	50	50
H6609	090	0	1	04	01	H6609_090_0	3	4		01	12;		2		2			2		1	20	20
H6609	090	0	1	04	01	H6609_090_0	3	3		01	14a;		2		2			2		1	0	30
H6609	090	0	1	04	01	H6609_090_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	090	0	1	04	01	H6609_090_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	090	0	1	04	01	H6609_090_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	091	0	1	04	01	H6609_091_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	091	0	1	04	01	H6609_091_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	091	0	1	04	01	H6609_091_0	3	4		01	11a;11c;12;		2		2			2		1	20	20
H6609	091	0	1	04	01	H6609_091_0	3	5		01	15;		2		2			2		1	20	30
H6609	091	0	1	04	01	H6609_091_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	091	0	1	04	01	H6609_091_0	3	7		10		13c;14c;	2		2			2		1	50	50
H6609	091	0	1	04	01	H6609_091_0	3	3		01	14a;		2		2			2		1	0	30
H6609	092	0	1	04	01	H6609_092_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	092	0	1	04	01	H6609_092_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	092	0	1	04	01	H6609_092_0	3	3		01	14a;		2		2			2		1	0	30
H6609	092	0	1	04	01	H6609_092_0	3	4		01	11a;11c;12;		2		2			2		1	20	20
H6609	092	0	1	04	01	H6609_092_0	3	5		01	15;		2		2			2		1	20	30
H6609	092	0	1	04	01	H6609_092_0	3	6		01	11b;		2		2			2		1	25	25
H6609	092	0	1	04	01	H6609_092_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	092	0	1	04	01	H6609_092_0	3	8		10		13c;14c;	2		2			2		1	50	50
H6609	095	0	1	04	01	H6609_095_0	3	3		01	12;		2		2			2		1	0	20
H6609	095	0	1	04	01	H6609_095_0	3	9		10		13b;	1	15.00	2			2		1	50	50
H6609	095	0	1	04	01	H6609_095_0	3	8		10		13c;14c;	2		2			2		1	50	50
H6609	095	0	1	04	01	H6609_095_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	095	0	1	04	01	H6609_095_0	3	6		01	15;		2		2			2		1	20	30
H6609	095	0	1	04	01	H6609_095_0	3	5		01	11a;		2		2			2		1	20	20
H6609	095	0	1	04	01	H6609_095_0	3	4		01	14a;		2		2			2		1	0	30
H6609	095	0	1	04	01	H6609_095_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	095	0	1	04	01	H6609_095_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	096	0	1	04	01	H6609_096_0	3	5		01	11a;		2		2			2		1	20	20
H6609	096	0	1	04	01	H6609_096_0	3	4		01	14a;		2		2			2		1	0	30
H6609	096	0	1	04	01	H6609_096_0	3	3		01	12;		2		2			2		1	0	20
H6609	096	0	1	04	01	H6609_096_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	096	0	1	04	01	H6609_096_0	3	6		01	15;		2		2			2		1	20	30
H6609	096	0	1	04	01	H6609_096_0	3	9		10		13b;	1	15.00	2			2		1	50	50
H6609	096	0	1	04	01	H6609_096_0	3	8		10		13c;14c;16a;16b;	2		2			2		1	50	50
H6609	096	0	1	04	01	H6609_096_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	096	0	1	04	01	H6609_096_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	097	0	1	04	01	H6609_097_0	4	6		01	11a;11b;11c;		2		2			2		1	25	25
H6609	097	0	1	04	01	H6609_097_0	4	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	097	0	1	04	01	H6609_097_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	097	0	1	04	01	H6609_097_0	4	3		01	14a;		2		2			2		1	0	30
H6609	097	0	1	04	01	H6609_097_0	4	4		01	12;		2		2			2		1	20	20
H6609	097	0	1	04	01	H6609_097_0	4	5		01	15;		2		2			2		1	20	30
H6609	097	0	1	04	01	H6609_097_0	4	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	097	0	1	04	01	H6609_097_0	4	8		10		13c;14c;	2		2			2		1	50	50
H6609	097	0	1	04	01	H6609_097_0	4	9		10		13b;	1	10.00	2			2		1	50	50
H6609	098	0	1	04	01	H6609_098_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	098	0	1	04	01	H6609_098_0	3	8		01	11c;		2		2			2		1	40	40
H6609	098	0	1	04	01	H6609_098_0	3	9		10		13c;14c;16a;16b;	2		2			2		1	50	50
H6609	098	0	1	04	01	H6609_098_0	3	4		01	14a;		2		2			2		1	0	30
H6609	098	0	1	04	01	H6609_098_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	098	0	1	04	01	H6609_098_0	3	6		01	15;		2		2			2		1	20	30
H6609	098	0	1	04	01	H6609_098_0	3	5		01	11a;		2		2			2		1	20	20
H6609	098	0	1	04	01	H6609_098_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	098	0	1	04	01	H6609_098_0	3	10		10		13b;	1	15.00	2			2		1	50	50
H6609	098	0	1	04	01	H6609_098_0	3	3		01	12;		2		2			2		1	0	20
H6609	099	0	1	04	01	H6609_099_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	099	0	1	04	01	H6609_099_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	099	0	1	04	01	H6609_099_0	3	3		01	14a;		2		2			2		1	0	40
H6609	099	0	1	04	01	H6609_099_0	3	4		01	11a;11c;12;		2		2			2		1	20	20
H6609	099	0	1	04	01	H6609_099_0	3	5		01	15;		2		2			2		1	20	40
H6609	099	0	1	04	01	H6609_099_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	40	40
H6609	099	0	1	04	01	H6609_099_0	3	7		10		13c;14c;	2		2			2		1	50	50
H6609	099	0	1	04	01	H6609_099_0	3	8		10		13b;	1	10.00	2			2		1	50	50
H6609	100	0	1	04	01	H6609_100_0	3	10		10		13b;	1	15.00	2			2		1	50	50
H6609	100	0	1	04	01	H6609_100_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	100	0	1	04	01	H6609_100_0	3	9		10		13c;14c;16a;16b;	2		2			2		1	50	50
H6609	100	0	1	04	01	H6609_100_0	3	8		01	11b;11c;		2		2			2		1	40	40
H6609	100	0	1	04	01	H6609_100_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	100	0	1	04	01	H6609_100_0	3	6		01	15;		2		2			2		1	20	30
H6609	100	0	1	04	01	H6609_100_0	3	5		01	11a;		2		2			2		1	18	18
H6609	100	0	1	04	01	H6609_100_0	3	4		01	14a;		2		2			2		1	0	30
H6609	100	0	1	04	01	H6609_100_0	3	3		01	12;		2		2			2		1	0	20
H6609	100	0	1	04	01	H6609_100_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	102	0	1	04	01	H6609_102_0	3	7		10		13c;14c;16a;16b;	2		2			2		1	50	50
H6609	102	0	1	04	01	H6609_102_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	102	0	1	04	01	H6609_102_0	3	8		10		13b;	1	15.00	2			2		1	50	50
H6609	102	0	1	04	01	H6609_102_0	3	5		01	15;		2		2			2		1	20	30
H6609	102	0	1	04	01	H6609_102_0	3	4		01	14a;		2		2			2		1	0	30
H6609	102	0	1	04	01	H6609_102_0	3	3		01	12;		2		2			2		1	0	20
H6609	102	0	1	04	01	H6609_102_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	102	0	1	04	01	H6609_102_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	103	0	1	04	01	H6609_103_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	103	0	1	04	01	H6609_103_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	103	0	1	04	01	H6609_103_0	3	7		10		13c;14c;	2		2			2		1	50	50
H6609	103	0	1	04	01	H6609_103_0	3	8		10		13b;	1	15.00	2			2		1	50	50
H6609	103	0	1	04	01	H6609_103_0	3	3		01	12;		2		2			2		1	0	20
H6609	103	0	1	04	01	H6609_103_0	3	4		01	14a;		2		2			2		1	0	30
H6609	103	0	1	04	01	H6609_103_0	3	5		01	15;		2		2			2		1	20	30
H6609	103	0	1	04	01	H6609_103_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	104	0	1	04	01	H6609_104_0	3	3		01	14a;		2		2			2		1	0	50
H6609	104	0	1	04	01	H6609_104_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	104	0	1	04	01	H6609_104_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	104	0	1	04	01	H6609_104_0	3	4		01	12;		2		2			2		1	20	20
H6609	104	0	1	04	01	H6609_104_0	3	8		10		13b;	1	20.00	2			2		1	50	50
H6609	104	0	1	04	01	H6609_104_0	3	7		10		14c;	2		2			2		1	50	50
H6609	104	0	1	04	01	H6609_104_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	104	0	1	04	01	H6609_104_0	3	5		01	11a;		2		2			2		1	25	25
H6609	105	0	1	04	01	H6609_105_0	3	4		01	11a;12;		2		2			2		1	20	20
H6609	105	0	1	04	01	H6609_105_0	3	3		01	14a;		2		2			2		1	0	30
H6609	105	0	1	04	01	H6609_105_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	105	0	1	04	01	H6609_105_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	105	0	1	04	01	H6609_105_0	3	5		01	11c;		2		2			2		1	20	40
H6609	105	0	1	04	01	H6609_105_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	105	0	1	04	01	H6609_105_0	3	7		10		14c;	2		2			2		1	50	50
H6609	105	0	1	04	01	H6609_105_0	3	8		10		13b;	1	10.00	2			2		1	50	50
H6609	106	0	1	04	01	H6609_106_0	3	4		01	11a;12;		2		2			2		1	20	20
H6609	106	0	1	04	01	H6609_106_0	3	3		01	14a;		2		2			2		1	0	35
H6609	106	0	1	04	01	H6609_106_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	106	0	1	04	01	H6609_106_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	106	0	1	04	01	H6609_106_0	3	5		01	11b;11c;		2		2			2		1	25	25
H6609	106	0	1	04	01	H6609_106_0	3	8		10		13b;	1	20.00	2			2		1	50	50
H6609	106	0	1	04	01	H6609_106_0	3	7		10		14c;16a;	2		2			2		1	50	50
H6609	106	0	1	04	01	H6609_106_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	35	35
H6609	107	0	1	04	01	H6609_107_0	3	1		11	9d;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	107	0	1	04	01	H6609_107_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	107	0	1	04	01	H6609_107_0	3	3		01	14a;		2		2			2		1	0	35
H6609	107	0	1	04	01	H6609_107_0	3	4		01	12;		2		2			2		1	20	20
H6609	107	0	1	04	01	H6609_107_0	3	9		10		13b;	1	20.00	2			2		1	50	50
H6609	107	0	1	04	01	H6609_107_0	3	5		01	11a;		2		2			2		1	25	25
H6609	107	0	1	04	01	H6609_107_0	3	6		01	11c;		2		2			2		1	25	35
H6609	107	0	1	04	01	H6609_107_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;15;16b;17a;17b;18a;	13d;14b;	2		2			2		1	35	35
H6609	107	0	1	04	01	H6609_107_0	3	8		10		14c;	2		2			2		1	50	50
H6609	108	0	1	04	01	H6609_108_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	40	40
H6609	108	0	1	04	01	H6609_108_0	3	7		10		13c;14c;	2		2			2		1	50	50
H6609	108	0	1	04	01	H6609_108_0	3	8		10		13b;	1	25.00	2			2		1	50	50
H6609	108	0	1	04	01	H6609_108_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	108	0	1	04	01	H6609_108_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	108	0	1	04	01	H6609_108_0	3	3		01	14a;		2		2			2		1	0	50
H6609	108	0	1	04	01	H6609_108_0	3	4		01	12;		2		2			2		1	20	20
H6609	108	0	1	04	01	H6609_108_0	3	5		01	15;		2		2			2		1	20	40
H6609	110	0	1	04	01	H6609_110_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	110	0	1	04	01	H6609_110_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	110	0	1	04	01	H6609_110_0	3	3		01	14a;		2		2			2		1	0	50
H6609	110	0	1	04	01	H6609_110_0	3	8		10		13b;	1	25.00	2			2		1	50	50
H6609	110	0	1	04	01	H6609_110_0	3	5		01	11a;		2		2			2		1	30	30
H6609	110	0	1	04	01	H6609_110_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	40	40
H6609	110	0	1	04	01	H6609_110_0	3	7		10		13c;14c;16a;16b;	2		2			2		1	50	50
H6609	110	0	1	04	01	H6609_110_0	3	4		01	12;		2		2			2		1	20	20
H6609	111	0	1	04	01	H6609_111_0	2	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	111	0	1	04	01	H6609_111_0	2	2		01	10a;		2		1	250.00	250.00	2		2		
H6609	111	0	1	04	01	H6609_111_0	2	3		01	14a;		2		2			2		1	0	50
H6609	111	0	1	04	01	H6609_111_0	2	8		10		13b;	1	25.00	2			2		1	50	50
H6609	111	0	1	04	01	H6609_111_0	2	5		01	15;		2		2			2		1	20	30
H6609	111	0	1	04	01	H6609_111_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	111	0	1	04	01	H6609_111_0	2	7		10		10b;13c;14c;16a;16b;	2		2			2		1	50	50
H6609	111	0	1	04	01	H6609_111_0	2	4		01	11a;11b;11c;12;		2		2			2		1	20	20
H6609	112	0	1	04	01	H6609_112_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	112	0	1	04	01	H6609_112_0	3	3		01	14a;		2		2			2		1	0	50
H6609	112	0	1	04	01	H6609_112_0	3	4		01	11a;12;		2		2			2		1	20	20
H6609	112	0	1	04	01	H6609_112_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	112	0	1	04	01	H6609_112_0	3	6		10		13c;14c;	2		2			2		1	50	50
H6609	112	0	1	04	01	H6609_112_0	3	7		10		13b;	1	25.00	2			2		1	50	50
H6609	112	0	1	04	01	H6609_112_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	40	40
H6609	113	0	1	04	01	H6609_113_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	113	0	1	04	01	H6609_113_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	113	0	1	04	01	H6609_113_0	3	3		01	14a;		2		2			2		1	0	30
H6609	113	0	1	04	01	H6609_113_0	3	8		10		13b;	1	50.00	2			2		1	50	50
H6609	113	0	1	04	01	H6609_113_0	3	5		01	8b1;		2		2			2		1	25	30
H6609	113	0	1	04	01	H6609_113_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	113	0	1	04	01	H6609_113_0	3	7		10		13c;14c;	2		2			2		1	50	50
H6609	113	0	1	04	01	H6609_113_0	3	4		01	12;15;		2		2			2		1	20	20
H6609	115	0	1	04	01	H6609_115_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	115	0	1	04	01	H6609_115_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	115	0	1	04	01	H6609_115_0	3	3		01	14a;		2		2			2		1	0	50
H6609	115	0	1	04	01	H6609_115_0	3	4		01	6;12;		2		2			2		1	20	20
H6609	115	0	1	04	01	H6609_115_0	3	9		10		13b;	1	25.00	2			2		1	50	50
H6609	115	0	1	04	01	H6609_115_0	3	6		01	11c;		2		2			2		1	30	40
H6609	115	0	1	04	01	H6609_115_0	3	7		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	40	40
H6609	115	0	1	04	01	H6609_115_0	3	8		10		13c;14c;	2		2			2		1	50	50
H6609	115	0	1	04	01	H6609_115_0	3	5		01	11a;		2		2			2		1	24	24
H6609	116	0	1	04	01	H6609_116_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	116	0	1	04	01	H6609_116_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	116	0	1	04	01	H6609_116_0	3	3		01	12;		2		2			2		1	0	20
H6609	116	0	1	04	01	H6609_116_0	3	8		10		13b;	1	20.00	2			2		1	50	50
H6609	116	0	1	04	01	H6609_116_0	3	5		10		18a;18b;	2		2			2		1	25	25
H6609	116	0	1	04	01	H6609_116_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	116	0	1	04	01	H6609_116_0	3	7		10		13c;14c;16a;16b;	2		2			2		1	50	50
H6609	116	0	1	04	01	H6609_116_0	3	4		01	14a;		2		2			2		1	0	30
H6609	117	0	1	04	01	H6609_117_0	4	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	117	0	1	04	01	H6609_117_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	117	0	1	04	01	H6609_117_0	4	3		01	12;		2		2			2		1	0	20
H6609	117	0	1	04	01	H6609_117_0	4	8		10		13b;	1	20.00	2			2		1	50	50
H6609	117	0	1	04	01	H6609_117_0	4	5		01	15;		2		2			2		1	20	30
H6609	117	0	1	04	01	H6609_117_0	4	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	117	0	1	04	01	H6609_117_0	4	7		10		13c;14c;16a;16b;	2		2			2		1	50	50
H6609	117	0	1	04	01	H6609_117_0	4	4		01	14a;		2		2			2		1	0	30
H6609	118	0	1	04	01	H6609_118_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	118	0	1	04	01	H6609_118_0	3	2		01	10a;		2		1	250.00	250.00	2		2		
H6609	118	0	1	04	01	H6609_118_0	3	3		01	14a;		2		2			2		1	0	40
H6609	118	0	1	04	01	H6609_118_0	3	4		01	12;		2		2			2		1	20	20
H6609	118	0	1	04	01	H6609_118_0	3	9		10		13b;	1	15.00	2			2		1	50	50
H6609	118	0	1	04	01	H6609_118_0	3	6		01	11a;11b;11c;		2		2			2		1	25	25
H6609	118	0	1	04	01	H6609_118_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	40	40
H6609	118	0	1	04	01	H6609_118_0	3	8		10		13c;14c;16a;16b;	2		2			2		1	50	50
H6609	118	0	1	04	01	H6609_118_0	3	5		01	15;		2		2			2		1	20	40
H6609	119	0	1	04	01	H6609_119_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	119	0	1	04	01	H6609_119_0	3	8		10		13c;14c;	2		2			2		1	50	50
H6609	119	0	1	04	01	H6609_119_0	3	9		10		13b;	1	15.00	2			2		1	50	50
H6609	119	0	1	04	01	H6609_119_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	119	0	1	04	01	H6609_119_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	119	0	1	04	01	H6609_119_0	3	3		01	14a;		2		2			2		1	0	30
H6609	119	0	1	04	01	H6609_119_0	3	4		01	12;		2		2			2		1	20	20
H6609	119	0	1	04	01	H6609_119_0	3	5		01	15;		2		2			2		1	20	30
H6609	119	0	1	04	01	H6609_119_0	3	6		01	11a;11b;11c;		2		2			2		1	25	25
H6609	120	0	1	04	01	H6609_120_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	120	0	1	04	01	H6609_120_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	120	0	1	04	01	H6609_120_0	3	3		01	14a;		2		2			2		1	0	30
H6609	120	0	1	04	01	H6609_120_0	3	4		01	12;		2		2			2		1	20	20
H6609	120	0	1	04	01	H6609_120_0	3	5		01	11a;11b;11c;		2		2			2		1	25	25
H6609	120	0	1	04	01	H6609_120_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	120	0	1	04	01	H6609_120_0	3	7		10		13c;14c;	2		2			2		1	50	50
H6609	120	0	1	04	01	H6609_120_0	3	8		10		13b;	1	15.00	2			2		1	50	50
H6609	121	0	1	04	01	H6609_121_0	3	9		10		13b;	1	25.00	2			2		1	50	50
H6609	121	0	1	04	01	H6609_121_0	3	8		10		13c;14c;16a;	2		2			2		1	50	50
H6609	121	0	1	04	01	H6609_121_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	121	0	1	04	01	H6609_121_0	3	6		01	11a;		2		2			2		1	25	25
H6609	121	0	1	04	01	H6609_121_0	3	5		01	15;		2		2			2		1	20	30
H6609	121	0	1	04	01	H6609_121_0	3	4		01	14a;		2		2			2		1	0	30
H6609	121	0	1	04	01	H6609_121_0	3	3		01	12;		2		2			2		1	0	20
H6609	121	0	1	04	01	H6609_121_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	121	0	1	04	01	H6609_121_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	122	0	1	04	01	H6609_122_0	3	7		10		13c;14c;	2		2			2		1	50	50
H6609	122	0	1	04	01	H6609_122_0	3	8		10		13b;	1	15.00	2			2		1	50	50
H6609	122	0	1	04	01	H6609_122_0	3	5		01	11c;		2		2			2		1	25	25
H6609	122	0	1	04	01	H6609_122_0	3	4		01	11a;11b;12;		2		2			2		1	20	20
H6609	122	0	1	04	01	H6609_122_0	3	3		01	14a;		2		2			2		1	0	50
H6609	122	0	1	04	01	H6609_122_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	122	0	1	04	01	H6609_122_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	122	0	1	04	01	H6609_122_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	123	0	1	04	01	H6609_123_0	3	1		11	9d;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	123	0	1	04	01	H6609_123_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	123	0	1	04	01	H6609_123_0	3	3		01	12;		2		2			2		1	0	20
H6609	123	0	1	04	01	H6609_123_0	3	4		01	14a;		2		2			2		1	0	50
H6609	123	0	1	04	01	H6609_123_0	3	5		01	15;		2		2			2		1	20	50
H6609	123	0	1	04	01	H6609_123_0	3	6		01	11a;		2		2			2		1	30	30
H6609	123	0	1	04	01	H6609_123_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;17b;18a;	13c;13d;14b;14c;16a;	2		2			2		1	50	50
H6609	123	0	1	04	01	H6609_123_0	3	8		10		13b;	1	25.00	2			2		1	50	50
H6609	124	0	1	04	01	H6609_124_0	3	5		01	11a;11b;		2		2			2		1	29	29
H6609	124	0	1	04	01	H6609_124_0	3	4		01	12;		2		2			2		1	20	20
H6609	124	0	1	04	01	H6609_124_0	3	3		01	14a;		2		2			2		1	0	40
H6609	124	0	1	04	01	H6609_124_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	124	0	1	04	01	H6609_124_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	124	0	1	04	01	H6609_124_0	3	8		10		13b;	1	15.00	2			2		1	50	50
H6609	124	0	1	04	01	H6609_124_0	3	7		10		13c;14c;16a;16b;	2		2			2		1	50	50
H6609	124	0	1	04	01	H6609_124_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11c;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	40	40
H6609	125	0	1	04	01	H6609_125_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	125	0	1	04	01	H6609_125_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	125	0	1	04	01	H6609_125_0	3	3		01	14a;		2		2			2		1	0	35
H6609	125	0	1	04	01	H6609_125_0	3	4		01	11a;11b;11c;12;		2		2			2		1	20	20
H6609	125	0	1	04	01	H6609_125_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	35	35
H6609	125	0	1	04	01	H6609_125_0	3	6		10		13c;14c;16a;16b;	2		2			2		1	50	50
H6609	125	0	1	04	01	H6609_125_0	3	7		10		13b;	1	15.00	2			2		1	50	50
H6609	126	0	1	04	01	H6609_126_0	3	8		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;17b;18a;	13c;13d;14b;14c;	2		2			2		1	50	50
H6609	126	0	1	04	01	H6609_126_0	3	9		10		13b;	1	25.00	2			2		1	50	50
H6609	126	0	1	04	01	H6609_126_0	3	7		01	11b;11c;		2		2			2		1	20	50
H6609	126	0	1	04	01	H6609_126_0	3	6		01	15;		2		2			2		1	20	20
H6609	126	0	1	04	01	H6609_126_0	3	5		01	11a;		2		2			2		1	15	15
H6609	126	0	1	04	01	H6609_126_0	3	4		01	14a;		2		2			2		1	0	50
H6609	126	0	1	04	01	H6609_126_0	3	3		01	12;		2		2			2		1	0	20
H6609	126	0	1	04	01	H6609_126_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	126	0	1	04	01	H6609_126_0	3	1		11	9d;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	127	0	1	04	01	H6609_127_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	127	0	1	04	01	H6609_127_0	3	7		10		13c;14c;	2		2			2		1	50	50
H6609	127	0	1	04	01	H6609_127_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	127	0	1	04	01	H6609_127_0	3	5		01	11a;		2		2			2		1	25	25
H6609	127	0	1	04	01	H6609_127_0	3	4		01	12;		2		2			2		1	20	20
H6609	127	0	1	04	01	H6609_127_0	3	3		01	14a;		2		2			2		1	0	30
H6609	127	0	1	04	01	H6609_127_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	127	0	1	04	01	H6609_127_0	3	8		10		13b;	1	15.00	2			2		1	50	50
H6609	128	0	1	04	01	H6609_128_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13c;13d;14b;14c;	2		2			2		1	50	50
H6609	128	0	1	04	01	H6609_128_0	3	7		10		13b;	1	15.00	2			2		1	50	50
H6609	128	0	1	04	01	H6609_128_0	3	4		01	12;		2		2			2		1	20	20
H6609	128	0	1	04	01	H6609_128_0	3	5		01	11a;		2		2			2		1	30	30
H6609	128	0	1	04	01	H6609_128_0	3	3		01	14a;		2		2			2		1	0	50
H6609	128	0	1	04	01	H6609_128_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	128	0	1	04	01	H6609_128_0	3	1		11	9d;17b;	9d;	2		1	0.00	0.00	2		2		
H6609	129	0	1	04	01	H6609_129_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	129	0	1	04	01	H6609_129_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	129	0	1	04	01	H6609_129_0	3	3		01	14a;		2		2			2		1	0	30
H6609	129	0	1	04	01	H6609_129_0	3	4		01	12;		2		2			2		1	20	20
H6609	129	0	1	04	01	H6609_129_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	129	0	1	04	01	H6609_129_0	3	6		10		13c;14c;16a;16b;	2		2			2		1	50	50
H6609	129	0	1	04	01	H6609_129_0	3	7		10		13b;	1	25.00	2			2		1	50	50
H6609	130	0	1	04	01	H6609_130_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	130	0	1	04	01	H6609_130_0	3	2		01	10a;		2		1	400.00	400.00	2		2		
H6609	130	0	1	04	01	H6609_130_0	3	3		01	14a;		2		2			2		1	0	40
H6609	130	0	1	04	01	H6609_130_0	3	4		01	12;		2		2			2		1	20	20
H6609	130	0	1	04	01	H6609_130_0	3	9		10		13b;	1	25.00	2			2		1	50	50
H6609	130	0	1	04	01	H6609_130_0	3	6		01	11b;		2		2			2		1	30	30
H6609	130	0	1	04	01	H6609_130_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11c;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	40	40
H6609	130	0	1	04	01	H6609_130_0	3	8		10		13c;14c;	2		2			2		1	50	50
H6609	130	0	1	04	01	H6609_130_0	3	5		01	11a;		2		2			2		1	25	25
H6609	131	0	1	04	01	H6609_131_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	131	0	1	04	01	H6609_131_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	131	0	1	04	01	H6609_131_0	3	3		01	14a;		2		2			2		1	0	50
H6609	131	0	1	04	01	H6609_131_0	3	8		10		13b;	1	25.00	2			2		1	50	50
H6609	131	0	1	04	01	H6609_131_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;15;16b;17a;18a;	13c;13d;14b;14c;	2		2			2		1	50	50
H6609	131	0	1	04	01	H6609_131_0	3	6		01	11b;11c;		2		2			2		1	40	40
H6609	131	0	1	04	01	H6609_131_0	3	5		01	11a;		2		2			2		1	30	30
H6609	131	0	1	04	01	H6609_131_0	3	4		01	12;		2		2			2		1	20	20
H6609	132	0	1	04	01	H6609_132_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	132	0	1	04	01	H6609_132_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;15;16b;17a;18a;	13c;13d;14b;14c;	2		2			2		1	50	50
H6609	132	0	1	04	01	H6609_132_0	3	5		01	11a;11b;11c;		2		2			2		1	30	30
H6609	132	0	1	04	01	H6609_132_0	3	4		01	12;		2		2			2		1	20	20
H6609	132	0	1	04	01	H6609_132_0	3	3		01	14a;		2		2			2		1	0	50
H6609	132	0	1	04	01	H6609_132_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	132	0	1	04	01	H6609_132_0	3	7		10		13b;	1	10.00	2			2		1	50	50
H6609	133	0	1	04	01	H6609_133_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	133	0	1	04	01	H6609_133_0	3	1		11	9d;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	133	0	1	04	01	H6609_133_0	3	3		01	14a;		2		2			2		1	0	50
H6609	133	0	1	04	01	H6609_133_0	3	7		10		13b;	1	25.00	2			2		1	50	50
H6609	133	0	1	04	01	H6609_133_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;13d;14b;14c;16a;16b;	2		2			2		1	50	50
H6609	133	0	1	04	01	H6609_133_0	3	5		01	11a;		2		2			2		1	40	40
H6609	133	0	1	04	01	H6609_133_0	3	4		01	12;		2		2			2		1	20	20
H6609	135	0	1	04	01	H6609_135_0	3	2		01	10a;		2		1	350.00	350.00	2		2		
H6609	135	0	1	04	01	H6609_135_0	3	1		11	9d;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	135	0	1	04	01	H6609_135_0	3	3		01	14a;		2		2			2		1	0	50
H6609	135	0	1	04	01	H6609_135_0	3	4		01	12;		2		2			2		1	20	20
H6609	135	0	1	04	01	H6609_135_0	3	5		01	11a;11b;11c;		2		2			2		1	40	40
H6609	135	0	1	04	01	H6609_135_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;15;16b;17a;17b;18a;	13c;13d;14b;14c;16a;	2		2			2		1	50	50
H6609	135	0	1	04	01	H6609_135_0	3	7		10		13b;	1	25.00	2			2		1	50	50
H6609	135	0	1	04	01	H6609_135_0	3	8		10		16b;	2		2			2		1	50	55
H6609	137	0	1	04	01	H6609_137_0	3	2		01	10a;		2		1	250.00	250.00	2		2		
H6609	137	0	1	04	01	H6609_137_0	3	1		11	9d;	9d;17a;	2		1	0.00	0.00	2		2		
H6609	137	0	1	04	01	H6609_137_0	3	3		01	14a;		2		2			2		1	0	30
H6609	137	0	1	04	01	H6609_137_0	3	7		10		13b;	1	25.00	2			2		1	50	50
H6609	137	0	1	04	01	H6609_137_0	3	6		10		10b;13c;14c;	2		2			2		1	50	50
H6609	137	0	1	04	01	H6609_137_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;15;16b;17a;17b;18a;	13d;14b;	2		2			2		1	30	30
H6609	137	0	1	04	01	H6609_137_0	3	4		01	12;		2		2			2		1	20	20
H6609	138	0	1	04	01	H6609_138_0	3	1		11	9d;	9d;	2		1	0.00	0.00	2		2		
H6609	138	0	1	04	01	H6609_138_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	138	0	1	04	01	H6609_138_0	3	3		01	14a;		2		2			2		1	0	50
H6609	138	0	1	04	01	H6609_138_0	3	4		01	12;		2		2			2		1	20	20
H6609	138	0	1	04	01	H6609_138_0	3	5		01	11a;		2		2			2		1	30	30
H6609	138	0	1	04	01	H6609_138_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;13d;14b;14c;	2		2			2		1	50	50
H6609	138	0	1	04	01	H6609_138_0	3	7		10		13b;	1	10.00	2			2		1	50	50
H6609	140	0	1	04	01	H6609_140_0	3	3		01	14a;		2		2			2		1	0	50
H6609	140	0	1	04	01	H6609_140_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	140	0	1	04	01	H6609_140_0	3	5		01	12;		2		2			2		1	20	20
H6609	140	0	1	04	01	H6609_140_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;13d;14b;14c;	2		2			2		1	50	50
H6609	140	0	1	04	01	H6609_140_0	3	7		10		13b;	1	10.00	2			2		1	50	50
H6609	140	0	1	04	01	H6609_140_0	3	4		01	11a;		2		2			2		1	15	15
H6609	140	0	1	04	01	H6609_140_0	3	1		11	9d;	9d;	2		1	0.00	0.00	2		2		
H6609	142	1	1	04	01	H6609_142_1	3	3		01	14a;		2		2			2		1	0	50
H6609	142	1	1	04	01	H6609_142_1	3	1		11	9d;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	142	1	1	04	01	H6609_142_1	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;13d;14b;14c;16a;	2		2			2		1	50	50
H6609	142	1	1	04	01	H6609_142_1	3	6		10		13b;	1	20.00	2			2		1	50	50
H6609	142	1	1	04	01	H6609_142_1	3	7		10		16b;	2		2			2		1	50	55
H6609	142	1	1	04	01	H6609_142_1	3	4		01	11a;12;		2		2			2		1	20	20
H6609	142	1	1	04	01	H6609_142_1	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	142	2	1	04	01	H6609_142_2	3	3		01	14a;		2		2			2		1	0	50
H6609	142	2	1	04	01	H6609_142_2	3	1		11	9d;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	142	2	1	04	01	H6609_142_2	3	5		01	12;		2		2			2		1	20	20
H6609	142	2	1	04	01	H6609_142_2	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;13d;14b;14c;16a;	2		2			2		1	50	50
H6609	142	2	1	04	01	H6609_142_2	3	7		10		13b;	1	20.00	2			2		1	50	50
H6609	142	2	1	04	01	H6609_142_2	3	8		10		16b;	2		2			2		1	50	55
H6609	142	2	1	04	01	H6609_142_2	3	4		01	11a;		2		2			2		1	15	15
H6609	142	2	1	04	01	H6609_142_2	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	143	0	1	04	01	H6609_143_0	4	3		01	11a;		2		2			2		1	15	15
H6609	143	0	1	04	01	H6609_143_0	4	1		11	6;9d;	9d;	2		1	0.00	0.00	2		2		
H6609	143	0	1	04	01	H6609_143_0	4	5		10		13c;14c;	2		2			2		1	50	50
H6609	143	0	1	04	01	H6609_143_0	4	6		10		13b;	1	10.00	2			2		1	50	50
H6609	143	0	1	04	01	H6609_143_0	4	4		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;10a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;	13d;14b;	2		2			2		1	20	20
H6609	143	0	1	04	01	H6609_143_0	4	2		01	8a2;14a;		2		2			2		1	0	20
H6609	144	1	1	04	01	H6609_144_1	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	144	1	1	04	01	H6609_144_1	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	144	1	1	04	01	H6609_144_1	3	4		01	14a;		2		2			2		1	0	30
H6609	144	1	1	04	01	H6609_144_1	3	5		01	11a;		2		2			2		1	20	20
H6609	144	1	1	04	01	H6609_144_1	3	6		01	15;		2		2			2		1	20	30
H6609	144	1	1	04	01	H6609_144_1	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	144	1	1	04	01	H6609_144_1	3	8		01	11b;11c;		2		2			2		1	40	40
H6609	144	1	1	04	01	H6609_144_1	3	9		10		13c;14c;16a;16b;	2		2			2		1	50	50
H6609	144	1	1	04	01	H6609_144_1	3	3		01	12;		2		2			2		1	0	20
H6609	144	1	1	04	01	H6609_144_1	3	10		10		13b;	1	15.00	2			2		1	50	50
H6609	144	2	1	04	01	H6609_144_2	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	144	2	1	04	01	H6609_144_2	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	144	2	1	04	01	H6609_144_2	3	4		01	14a;		2		2			2		1	0	30
H6609	144	2	1	04	01	H6609_144_2	3	5		01	11a;		2		2			2		1	20	20
H6609	144	2	1	04	01	H6609_144_2	3	6		01	15;		2		2			2		1	20	30
H6609	144	2	1	04	01	H6609_144_2	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	144	2	1	04	01	H6609_144_2	3	8		01	11b;11c;		2		2			2		1	40	40
H6609	144	2	1	04	01	H6609_144_2	3	9		10		13c;14c;16a;16b;	2		2			2		1	50	50
H6609	144	2	1	04	01	H6609_144_2	3	3		01	12;		2		2			2		1	0	20
H6609	144	2	1	04	01	H6609_144_2	3	10		10		13b;	1	15.00	2			2		1	50	50
H6609	145	0	1	04	01	H6609_145_0	3	3		01	14a;		2		2			2		1	0	50
H6609	145	0	1	04	01	H6609_145_0	3	4		01	12;		2		2			2		1	20	20
H6609	145	0	1	04	01	H6609_145_0	3	5		01	15;		2		2			2		1	20	40
H6609	145	0	1	04	01	H6609_145_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	40	40
H6609	145	0	1	04	01	H6609_145_0	3	7		10		13c;14c;16a;16b;18a;	2		2			2		1	50	50
H6609	145	0	1	04	01	H6609_145_0	3	8		10		13b;	1	25.00	2			2		1	50	50
H6609	145	0	1	04	01	H6609_145_0	3	2		01	10a;		2		1	300.00	300.00	2		2		
H6609	145	0	1	04	01	H6609_145_0	3	1		11	9d;17b;	9d;17a;17b;18b;	2		1	0.00	0.00	2		2		
H6609	146	0	1	04	01	H6609_146_0	3	9		10		13c;14c;16a;	2		2			2		1	50	50
H6609	146	0	1	04	01	H6609_146_0	3	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H6609	146	0	1	04	01	H6609_146_0	3	10		10		13b;	1	20.00	2			2		1	50	50
H6609	146	0	1	04	01	H6609_146_0	3	11		10		16b;	2		2			2		1	50	55
H6609	146	0	1	04	01	H6609_146_0	3	2		01	10a;		2		1	240.00	240.00	2		2		
H6609	146	0	1	04	01	H6609_146_0	3	3		01	12;		2		2			2		1	0	20
H6609	146	0	1	04	01	H6609_146_0	3	4		01	14a;		2		2			2		1	0	30
H6609	146	0	1	04	01	H6609_146_0	3	5		01	11a;		2		2			2		1	20	20
H6609	146	0	1	04	01	H6609_146_0	3	6		01	15;		2		2			2		1	20	30
H6609	146	0	1	04	01	H6609_146_0	3	7		10		18a;18b;	2		2			2		1	25	25
H6609	146	0	1	04	01	H6609_146_0	3	8		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H6609	801	0	1	04	01	H6609_801_0	2	1		01	6;14a;		2		2			2		1	0	0
H6609	801	0	1	04	01	H6609_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H6609	802	0	1	04	01	H6609_802_0	2	1		01	6;14a;		2		2			2		1	0	0
H6609	802	0	1	04	01	H6609_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H6609	803	0	1	04	01	H6609_803_0	2	1		01	6;14a;		2		2			2		1	0	0
H6609	803	0	1	04	01	H6609_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H6609	805	0	2	04	01	H6609_805_0	2	1		01	6;14a;		2		2			2		1	0	0
H6609	805	0	2	04	01	H6609_805_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H6609	806	0	2	04	01	H6609_806_0	2	1		01	6;14a;		2		2			2		1	0	0
H6609	806	0	2	04	01	H6609_806_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H6609	807	0	2	04	01	H6609_807_0	2	1		01	6;14a;		2		2			2		1	0	0
H6609	807	0	2	04	01	H6609_807_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H6609	816	0	1	04	01	H6609_816_0	1	1		01	6;14a;		2		2			2		1	0	0
H6609	816	0	1	04	01	H6609_816_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H6743	001	0	1	04	01	H6743_001_0	7	10	Health Education	10		14c;	2		2			2		2		
H6743	001	0	1	04	01	H6743_001_0	7	8	Home Health	01	6;		2		2			2		1	15	15
H6743	001	0	1	04	01	H6743_001_0	7	1	Primary Care Physician Services	01	7a;		2		1	40.00	40.00	2		2		
H6743	001	0	1	04	01	H6743_001_0	7	9	Laboratory Services	01	8a2;		2		2			2		1	25	25
H6743	001	0	1	04	01	H6743_001_0	7	7	Preventive Services	11	9d;11c;14a;14d;14e;17b;	9d;	2		2			2		2		
H6743	001	0	1	04	01	H6743_001_0	7	6	Diagnostic Tests	01	8a1;		2		2			2		1	30	30
H6743	001	0	1	04	01	H6743_001_0	7	5	Ambulance	01	10a;		2		2			2		1	20	20
H6743	001	0	1	04	01	H6743_001_0	7	4	Chiropractic Services	01	7b;		2		2			2		1	50	50
H6743	001	0	1	04	01	H6743_001_0	7	3	Outpatient Services	01	3-1;3-2;3-3;5;7c;7e;7f;7g;7h;7i;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;15;		2		2			2		1	30	30
H6743	001	0	1	04	01	H6743_001_0	7	2	Specialist Services	01	7d;16b;17a;18a;		2		1	50.00	50.00	2		2		
H6743	002	0	1	04	01	H6743_002_0	6	8	Home Health Services	01	6;		2		2			2		1	15	15
H6743	002	0	1	04	01	H6743_002_0	6	7	Radiology, ASC, DME, ESRD and Part B Rx	01	8b1;8b2;8b3;9b;11a;11b;12;15;		2		2			2		1	30	30
H6743	002	0	1	04	01	H6743_002_0	6	5	Ambulance	01	10a;		2		1	200.00	200.00	2		2		
H6743	002	0	1	04	01	H6743_002_0	6	1	Preventive Services	11	8a2;9d;11c;14a;14d;14e;17b;	9d;	2		2			2		2		
H6743	002	0	1	04	01	H6743_002_0	6	10	Health Club Membership	10		14c;	1	500.00	2			2		2		
H6743	002	0	1	04	01	H6743_002_0	6	6	Chiropractic Services	01	7b;		2		2			2		1	50	50
H6743	002	0	1	04	01	H6743_002_0	6	2	Primary Care Physician Services	01	7a;		2		1	30.00	30.00	2		2		
H6743	002	0	1	04	01	H6743_002_0	6	3	Specialist Services	11	3-1;3-2;3-3;5;7c;7d;7e;7f;7g;7h;7i;9c;16b;17a;18a;	17a;	2		1	40.00	40.00	2		2		
H6743	002	0	1	04	01	H6743_002_0	6	4	Outpatient Hosptial Services	01	9a;		2		1	325.00	325.00	2		2		
H6743	002	0	1	04	01	H6743_002_0	6	9	Diagnostic Tests	01	8a1;		2		2			2		1	30	30
H6743	002	0	1	04	01	H6743_002_0	6	11	Supplemental Eyewear	10		17b;	2		2			2		2		
H6743	003	0	1	04	01	H6743_003_0	7	1	Preventive Services	11	8a2;9d;11c;14a;14d;14e;17b;	9d;	2		2			2		2		
H6743	003	0	1	04	01	H6743_003_0	7	9	Diagnostic Tests	01	8a1;		2		2			2		1	30	30
H6743	003	0	1	04	01	H6743_003_0	7	8	Home Health Services	01	6;		2		2			2		1	15	15
H6743	003	0	1	04	01	H6743_003_0	7	7	Radiology, ASC, DME, ESRD and Part B Rx	01	8b1;8b2;8b3;9b;11a;11b;12;15;		2		2			2		1	30	30
H6743	003	0	1	04	01	H6743_003_0	7	10	Health Club Membership	10		14c;	1	500.00	2			2		2		
H6743	003	0	1	04	01	H6743_003_0	7	11	Supplemental Eyewear	10		17b;	2		2			2		2		
H6743	003	0	1	04	01	H6743_003_0	7	2	Primary Care Physician Services	01	7a;		2		1	30.00	30.00	2		2		
H6743	003	0	1	04	01	H6743_003_0	7	3	Specialist Services	11	3-1;3-2;3-3;5;7c;7d;7e;7f;7g;7h;7i;9c;16b;17a;18a;	17a;	2		1	40.00	40.00	2		2		
H6743	003	0	1	04	01	H6743_003_0	7	4	Outpatient Hosptial Services	01	9a;		2		1	325.00	325.00	2		2		
H6743	003	0	1	04	01	H6743_003_0	7	6	Chiropractic Services	01	7b;		2		2			2		1	50	50
H6743	003	0	1	04	01	H6743_003_0	7	5	Ambulance	01	10a;		2		1	200.00	200.00	2		2		
H6743	004	0	1	04	01	H6743_004_0	7	8	Home Health Services	01	6;		2		2			2		1	15	15
H6743	004	0	1	04	01	H6743_004_0	7	9	Diagnostic Tests	01	8a1;		2		2			2		1	20	20
H6743	004	0	1	04	01	H6743_004_0	7	6	Medicare Covered Chiropractic Services	01	7b;		2		1	15.00	15.00	2		2		
H6743	004	0	1	04	01	H6743_004_0	7	5	Ambulance	01	10a;		2		1	100.00	100.00	2		2		
H6743	004	0	1	04	01	H6743_004_0	7	4	Outpatient Services/ASC	01	9a;9b;		2		1	325.00	325.00	2		2		
H6743	004	0	1	04	01	H6743_004_0	7	3	Specialist services	11	3-1;3-2;3-3;5;7c;7d;7e;7f;7g;7h;7i;9c;16b;17a;18a;	17a;	2		1	30.00	30.00	2		2		
H6743	004	0	1	04	01	H6743_004_0	7	2	Preventive Services	11	8a2;9d;11c;14a;14d;14e;17b;	9d;18b;	2		2			2		2		
H6743	004	0	1	04	01	H6743_004_0	7	15	Routine Hearing	10		18a;	2		1	25.00	25.00	2		2		
H6743	004	0	1	04	01	H6743_004_0	7	14	Routine Podiatry	10		7f;	1	500.00	1	25.00	25.00	2		2		
H6743	004	0	1	04	01	H6743_004_0	7	13	Supplemental Chiropractic Services	10		7b;	1	500.00	1	15.00	15.00	2		2		
H6743	004	0	1	04	01	H6743_004_0	7	12	Preventive Dental	10		16a;	2		1	25.00	25.00	2		2		
H6743	004	0	1	04	01	H6743_004_0	7	11	Supplemental Eyewear	10		17b;	2		2			2		2		
H6743	004	0	1	04	01	H6743_004_0	7	10	Health Club Membership	10		14c;	1	500.00	2			2		2		
H6743	004	0	1	04	01	H6743_004_0	7	1	Primary Care Physician Services	01	7a;		2		1	25.00	25.00	2		2		
H6743	004	0	1	04	01	H6743_004_0	7	7	Radiolgy, DME and Part B Rx	01	8b1;8b2;8b3;11a;11b;12;15;		2		2			2		1	20	20
H6743	006	0	1	04	01	H6743_006_0	6	8	Home Health Services	01	6;		2		2			2		1	15	15
H6743	006	0	1	04	01	H6743_006_0	6	7	Preventive Services	11	9d;11c;14a;14d;14e;17b;	9d;	2		2			2		2		
H6743	006	0	1	04	01	H6743_006_0	6	6	Diagnostic Tests	01	8a1;		2		2			2		1	30	30
H6743	006	0	1	04	01	H6743_006_0	6	5	Ambulance	01	10a;		2		2			2		1	20	20
H6743	006	0	1	04	01	H6743_006_0	6	4	Chiropractic Services	01	7b;		2		2			2		1	50	50
H6743	006	0	1	04	01	H6743_006_0	6	3	Outpatient Services	01	3-1;3-2;3-3;5;7c;7e;7f;7g;7h;7i;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;15;		2		2			2		1	30	30
H6743	006	0	1	04	01	H6743_006_0	6	2	Specialist Services	01	7d;16b;17a;18a;		2		1	50.00	50.00	2		2		
H6743	006	0	1	04	01	H6743_006_0	6	9	Laboratory Services	01	8a2;		2		2			2		1	25	25
H6743	006	0	1	04	01	H6743_006_0	6	1	Primary Care Physician Services	01	7a;		2		1	40.00	40.00	2		2		
H6743	006	0	1	04	01	H6743_006_0	6	10	Health Education	10		14c;	2		2			2		2		
H6743	007	0	1	04	01	H6743_007_0	7	6	Diagnostic Tests	01	8a1;		2		2			2		1	30	30
H6743	007	0	1	04	01	H6743_007_0	7	7	Preventive Services	11	9d;11c;14a;14d;14e;17b;	9d;	2		2			2		2		
H6743	007	0	1	04	01	H6743_007_0	7	8	Home Health Services	01	6;		2		2			2		1	15	15
H6743	007	0	1	04	01	H6743_007_0	7	9	Laboratory Services	01	8a2;		2		2			2		1	25	25
H6743	007	0	1	04	01	H6743_007_0	7	1	Primary Care Physician Services	01	7a;		2		1	40.00	40.00	2		2		
H6743	007	0	1	04	01	H6743_007_0	7	10	Outpatient Hospital Services	01	9a;		2		2			2		1	40	40
H6743	007	0	1	04	01	H6743_007_0	7	11	Health Education	10		14c;	2		2			2		2		
H6743	007	0	1	04	01	H6743_007_0	7	2	Specialist Services	01	7d;16b;17a;18a;		2		1	50.00	50.00	2		2		
H6743	007	0	1	04	01	H6743_007_0	7	3	Outpatient Services	01	3-1;3-2;3-3;5;7c;7e;7f;7g;7h;7i;8b1;8b2;8b3;9b;9c;11a;11b;12;15;		2		2			2		1	30	30
H6743	007	0	1	04	01	H6743_007_0	7	4	Chiropractic Services	01	7b;		2		2			2		1	50	50
H6743	007	0	1	04	01	H6743_007_0	7	5	Ambulance	01	10a;		2		2			2		1	20	20
H6743	013	0	1	04	01	H6743_013_0	5	1	Primary Care Physician Services	01	7a;		2		1	30.00	30.00	2		2		
H6743	013	0	1	04	01	H6743_013_0	5	10	Comprehensive Dental, Eye &Hearing Exams	01	16b;17a;18a;		2		1	50.00	50.00	2		2		
H6743	013	0	1	04	01	H6743_013_0	5	11	Health Education	10		14c;	2		2			2		2		
H6743	013	0	1	04	01	H6743_013_0	5	2	Specialist Services	01	7d;		2		1	40.00	40.00	2		2		
H6743	013	0	1	04	01	H6743_013_0	5	3	Outpatient Services	01	3-1;3-2;3-3;5;7c;7e;7f;7g;7h;7i;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;15;		2		2			2		1	30	30
H6743	013	0	1	04	01	H6743_013_0	5	9	Laboratory Services	01	8a2;		2		2			2		1	25	25
H6743	013	0	1	04	01	H6743_013_0	5	5	Ambulance	01	10a;		2		2			2		1	20	20
H6743	013	0	1	04	01	H6743_013_0	5	6	Diagnostic Tests	01	8a1;		2		2			2		1	30	30
H6743	013	0	1	04	01	H6743_013_0	5	7	Preventive Services	11	9d;11c;14a;14d;14e;17b;	9d;	2		2			2		2		
H6743	013	0	1	04	01	H6743_013_0	5	8	Home Health Services	01	6;		2		2			2		1	15	15
H6743	013	0	1	04	01	H6743_013_0	5	4	Chiropractic Services	01	7b;		2		2			2		1	50	50
H6743	014	0	1	04	01	H6743_014_0	6	4	Chiropractic Services	01	7b;		2		2			2		1	50	50
H6743	014	0	1	04	01	H6743_014_0	6	5	Ambulance	01	10a;		2		2			2		1	20	20
H6743	014	0	1	04	01	H6743_014_0	6	6	Diagnostic Tests	01	8a1;		2		2			2		1	30	30
H6743	014	0	1	04	01	H6743_014_0	6	7	Preventive Services	11	9d;11c;14a;14d;14e;17b;	9d;	2		2			2		2		
H6743	014	0	1	04	01	H6743_014_0	6	8	Home Health	01	6;		2		2			2		1	15	15
H6743	014	0	1	04	01	H6743_014_0	6	9	Laboratory Services	01	8a2;		2		2			2		1	25	25
H6743	014	0	1	04	01	H6743_014_0	6	1	Primary Care Physician Services	01	7a;		2		1	40.00	40.00	2		2		
H6743	014	0	1	04	01	H6743_014_0	6	10	Health Education	10		14c;	2		2			2		2		
H6743	014	0	1	04	01	H6743_014_0	6	2	Specialist Services	01	7d;16b;17a;18a;		2		1	50.00	50.00	2		2		
H6743	014	0	1	04	01	H6743_014_0	6	3	Outpatient Services	01	3-1;3-2;3-3;5;7c;7e;7f;7g;7h;7i;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;15;		2		2			2		1	30	30
H6743	015	0	1	04	01	H6743_015_0	5	5	Ambulance	01	10a;		2		1	200.00	200.00	2		2		
H6743	015	0	1	04	01	H6743_015_0	5	4	Outpatient Hosptial Services	01	9a;		2		1	325.00	325.00	2		2		
H6743	015	0	1	04	01	H6743_015_0	5	9	Diagnostic Tests	01	8a1;		2		2			2		1	30	30
H6743	015	0	1	04	01	H6743_015_0	5	8	Home Health Services	01	6;		2		2			2		1	15	15
H6743	015	0	1	04	01	H6743_015_0	5	7	Radiology, ASC, DME, ESRD and Part B Rx	01	8b1;8b2;8b3;9b;11a;11b;12;15;		2		2			2		1	30	30
H6743	015	0	1	04	01	H6743_015_0	5	6	Chiropractic Services	01	7b;		2		2			2		1	50	50
H6743	015	0	1	04	01	H6743_015_0	5	1	Preventive Services	11	8a2;9d;11c;14a;14d;14e;17b;	9d;	2		2			2		2		
H6743	015	0	1	04	01	H6743_015_0	5	10	Health Club Membership	10		14c;	1	500.00	2			2		2		
H6743	015	0	1	04	01	H6743_015_0	5	2	Primary Care Physician Services	01	7a;		2		1	30.00	30.00	2		2		
H6743	015	0	1	04	01	H6743_015_0	5	3	Specialist Services	11	3-1;3-2;3-3;5;7c;7d;7e;7f;7g;7h;7i;9c;16b;17a;18a;	17a;	2		1	40.00	40.00	2		2		
H6743	016	0	1	04	01	H6743_016_0	6	1	Preventive Services	11	8a2;9d;11c;14a;14d;14e;17b;	9d;	2		2			2		2		
H6743	016	0	1	04	01	H6743_016_0	6	8	Home Health Services	01	6;		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	8b1;8b2;8b3;9b;11a;11b;12;15;		2		2			2		1	30	30
H6743	016	0	1	04	01	H6743_016_0	6	6	Chiropractic Services	01	7b;		2		2			2		1	50	50
H6743	016	0	1	04	01	H6743_016_0	6	9	Diagnostic Tests	01	8a1;		2		2			2		1	30	30
H6743	016	0	1	04	01	H6743_016_0	6	4	Outpatient Hosptial Services	01	9a;		2		1	325.00	325.00	2		2		
H6743	016	0	1	04	01	H6743_016_0	6	3	Specialist Services	11	3-1;3-2;3-3;5;7c;7d;7e;7f;7g;7h;7i;9c;16b;17a;18a;	17a;	2		1	40.00	40.00	2		2		
H6743	016	0	1	04	01	H6743_016_0	6	2	Primary Care Physician Services	01	7a;		2		1	30.00	30.00	2		2		
H6743	016	0	1	04	01	H6743_016_0	6	10	Health Club Membership	10		14c;	1	500.00	2			2		2		
H6743	016	0	1	04	01	H6743_016_0	6	5	Ambulance	01	10a;		2		1	200.00	200.00	2		2		
H6743	017	0	1	04	01	H6743_017_0	7	14	Routine Podiatry	10		7f;	1	500.00	1	25.00	25.00	2		2		
H6743	017	0	1	04	01	H6743_017_0	7	13	Supplemental Chiropractic Services	10		7b;	1	300.00	1	15.00	15.00	2		2		
H6743	017	0	1	04	01	H6743_017_0	7	12	Preventive Dental	10		16a;	2		1	15.00	15.00	2		2		
H6743	017	0	1	04	01	H6743_017_0	7	11	Supplemental Eyewear	10		17b;	2		2			2		2		
H6743	017	0	1	04	01	H6743_017_0	7	10	Health Club Membership	10		14c;	1	500.00	2			2		2		
H6743	017	0	1	04	01	H6743_017_0	7	1	Primary Care Physician Services	01	7a;		2		1	25.00	25.00	2		2		
H6743	017	0	1	04	01	H6743_017_0	7	2	Preventive Services	11	8a2;9d;11c;14a;14d;14e;17b;	9d;	2		2			2		2		
H6743	017	0	1	04	01	H6743_017_0	7	9	Diagnostic Tests	01	8a1;		2		2			2		1	20	20
H6743	017	0	1	04	01	H6743_017_0	7	8	Home Health Services	01	6;		2		2			2		1	15	15
H6743	017	0	1	04	01	H6743_017_0	7	7	Radiolgy, DME and Part B Rx	01	8b1;8b2;8b3;11a;11b;12;15;		2		2			2		1	20	20
H6743	017	0	1	04	01	H6743_017_0	7	6	Medicare Covered Chiropractic Services	01	7b;		2		1	15.00	15.00	2		2		
H6743	017	0	1	04	01	H6743_017_0	7	5	Ambulance	01	10a;		2		1	100.00	100.00	2		2		
H6743	017	0	1	04	01	H6743_017_0	7	4	Outpatient Services/ASC	01	9a;9b;		2		1	325.00	325.00	2		2		
H6743	017	0	1	04	01	H6743_017_0	7	3	Specialist services	11	3-1;3-2;3-3;5;7c;7d;7e;7f;7g;7h;7i;9c;16b;17a;18a;	17a;	2		1	30.00	30.00	2		2		
H6786	002	0	1	04	01	H6786_002_0	8	1	$0 copay	11	9d;16b;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H6786	002	0	1	04	01	H6786_002_0	8	2	$65 copay	01	7b;7c;7d;7e;7f;7h;7i;		2		1	65.00	65.00	2		2		
H6786	002	0	1	04	01	H6786_002_0	8	3	$55 copay	01	7a;7g;		2		1	55.00	55.00	2		2		
H6786	002	0	1	04	01	H6786_002_0	8	4	40% coinsurance	11	3-1;3-2;3-3;5;6;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14a;14d;14e;17a;18a;	14b;	2		2			2		1	40	40
H6786	002	0	1	04	01	H6786_002_0	8	5	20% coinsurance	11	12;	16a;	2		2			2		1	20	20
H6786	002	0	1	04	01	H6786_002_0	8	6	Ambulance	01	10a;		2		1	210.00	210.00	2		1	20	20
H6786	002	0	1	04	01	H6786_002_0	8	7	30% Coinsurance	01	15;		2		2			2		1	30	30
H6786	002	0	1	04	01	H6786_002_0	8	8	$0 Copay	10		14c;	1	95.00	1	0.00	0.00	2		2		
H6786	801	0	1	04	01	H6786_801_0	5	1		01	6;14a;		2		2			2		1	0	0
H6786	801	0	1	04	01	H6786_801_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H6786	802	0	1	04	01	H6786_802_0	5	1		01	6;14a;		2		2			2		1	0	0
H6786	802	0	1	04	01	H6786_802_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H6786	803	0	1	04	01	H6786_803_0	5	1		01	6;14a;		2		2			2		1	0	0
H6786	803	0	1	04	01	H6786_803_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H6951	001	0	1	04	01	H6951_001_0	3	3	Gym Benefit and Smoking Cessation	10		14c;	1	70.00	2			2		1	0	30
H6951	001	0	1	04	01	H6951_001_0	3	1	Eye Exams	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	17a;17b;	2		2			2		1	30	30
H6951	001	0	1	04	01	H6951_001_0	3	2	Ambulance Services	01	10a;		2		1	200.00	200.00	2		2		
H6951	002	0	1	04	01	H6951_002_0	6	2	Ambulance Services	01	10a;		2		1	200.00	200.00	2		2		
H6951	002	0	1	04	01	H6951_002_0	6	1	Eye Exams	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	17a;	2		2			2		1	30	30
H6951	002	0	1	04	01	H6951_002_0	6	3	Gym Benefit and Smoking Cessation	10		14c;	1	70.00	2			2		1	0	30
H7006	001	0	1	04	01	H7006_001_0	6	1	Preventive Services	11	8a1;8a2;8b2;8b3;9d;11c;12;14a;14d;14e;17b;	9d;	2		2			2		2		
H7006	001	0	1	04	01	H7006_001_0	6	10	Routine Podiatry	10		7f;	1	500.00	1	25.00	25.00	2		2		
H7006	001	0	1	04	01	H7006_001_0	6	9	Supplemental Eyewear	10		17b;	2		2			2		2		
H7006	001	0	1	04	01	H7006_001_0	6	8	Preventive Dental	10		16a;	2		2			2		2		
H7006	001	0	1	04	01	H7006_001_0	6	7	Health Club Membership	10		14c;	1	500.00	2			2		2		
H7006	001	0	1	04	01	H7006_001_0	6	6	Diagnostic Radiology	01	8b1;		2		2			2		1	20	20
H7006	001	0	1	04	01	H7006_001_0	6	5	DME, Part B Drugs	01	11a;11b;15;		2		2			2		1	20	20
H7006	001	0	1	04	01	H7006_001_0	6	4	Ambulance	01	10a;		2		1	100.00	100.00	2		2		
H7006	001	0	1	04	01	H7006_001_0	6	3	Outpatient Services and ASC	01	9a;9b;		2		1	225.00	225.00	2		2		
H7006	001	0	1	04	01	H7006_001_0	6	2	Office Visits, Home Health	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;9c;16b;17a;18a;	17a;	2		1	30.00	30.00	2		2		
H7006	003	0	1	04	01	H7006_003_0	6	1	Preventive Services	11	8a1;8a2;9d;11c;14a;14d;14e;17b;	9d;	2		2			2		2		
H7006	003	0	1	04	01	H7006_003_0	6	8	Health Club Membership	10		14c;	1	500.00	2			2		2		
H7006	003	0	1	04	01	H7006_003_0	6	7	Part B Drugs and Outpatient X-Rays, ESRD	01	6;8b3;12;15;		2		2			2		1	20	20
H7006	003	0	1	04	01	H7006_003_0	6	6	Radiology	01	8b1;8b2;		2		2			2		1	30	30
H7006	003	0	1	04	01	H7006_003_0	6	9	Preventive Dental	10		16a;	2		1	35.00	35.00	2		2		
H7006	003	0	1	04	01	H7006_003_0	6	4	Ambulance	01	10a;		2		1	100.00	100.00	2		2		
H7006	003	0	1	04	01	H7006_003_0	6	3	Outpatient Services, ASC	01	9a;9b;		2		1	225.00	225.00	2		2		
H7006	003	0	1	04	01	H7006_003_0	6	2	Office Visits	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;9c;16b;17a;18a;	17a;	2		1	35.00	35.00	2		2		
H7006	003	0	1	04	01	H7006_003_0	6	10	Supplemental Eyewear	10		17b;	2		2			2		2		
H7006	003	0	1	04	01	H7006_003_0	6	5	DME	01	11a;11b;		2		2			2		1	30	30
H7006	005	0	1	04	01	H7006_005_0	7	1	Primary Care Physician Services	01	7a;		2		1	40.00	40.00	2		2		
H7006	005	0	1	04	01	H7006_005_0	7	9	Laboratory Services	01	8a2;		2		2			2		1	25	25
H7006	005	0	1	04	01	H7006_005_0	7	8	Home Health	01	6;		2		2			2		1	15	15
H7006	005	0	1	04	01	H7006_005_0	7	7	Preventive Services	11	9d;11c;14a;14d;14e;17b;	9d;	2		2			2		2		
H7006	005	0	1	04	01	H7006_005_0	7	6	Diagnostic Tests	01	8a1;		2		2			2		1	30	30
H7006	005	0	1	04	01	H7006_005_0	7	5	Ambulance	01	10a;		2		2			2		1	20	20
H7006	005	0	1	04	01	H7006_005_0	7	4	Chiropractic Services	01	7b;		2		2			2		1	50	50
H7006	005	0	1	04	01	H7006_005_0	7	3	Outpatient Services	01	3-1;3-2;3-3;5;7c;7e;7f;7g;7h;7i;8b1;8b2;8b3;9b;9c;11a;11b;12;15;		2		2			2		1	30	30
H7006	005	0	1	04	01	H7006_005_0	7	2	Specialist Services	01	7d;16b;17a;18a;		2		1	50.00	50.00	2		2		
H7006	005	0	1	04	01	H7006_005_0	7	11	Health Club Membership	10		14c;	1	250.00	2			2		2		
H7006	005	0	1	04	01	H7006_005_0	7	10	Outpatient Hosptial Services	01	9a;		2		2			2		1	40	40
H7006	006	0	1	04	01	H7006_006_0	5	7	Preventive Services	11	9d;11c;14a;14d;14e;17b;	9d;14c;	2		2			2		2		
H7006	006	0	1	04	01	H7006_006_0	5	6	Diagnostic Tests	01	8a1;		2		2			2		1	30	30
H7006	006	0	1	04	01	H7006_006_0	5	5	Ambulance	01	10a;		2		2			2		1	20	20
H7006	006	0	1	04	01	H7006_006_0	5	4	Chiropractic Services	01	7b;		2		2			2		1	50	50
H7006	006	0	1	04	01	H7006_006_0	5	9	Laboratory Services	01	8a2;		2		2			2		1	25	25
H7006	006	0	1	04	01	H7006_006_0	5	2	Specialist Services	01	7d;16b;17a;18a;		2		1	50.00	50.00	2		2		
H7006	006	0	1	04	01	H7006_006_0	5	10	Outpatient Hosptial Services	01	9a;		2		2			2		1	30	30
H7006	006	0	1	04	01	H7006_006_0	5	1	Primary Care Services	01	7a;		2		1	40.00	40.00	2		2		
H7006	006	0	1	04	01	H7006_006_0	5	8	Home Health	01	6;		2		2			2		1	15	15
H7006	006	0	1	04	01	H7006_006_0	5	3	Outpatient Services	01	3-1;3-2;3-3;5;7c;7e;7f;7g;7h;7i;8b1;8b2;8b3;9b;9c;11a;11b;12;15;		2		2			2		1	30	30
H7301	002	0	1	04	01	H7301_002_0	6	2	OON Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H7301	002	0	1	04	01	H7301_002_0	6	1	OON Standard Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	7f;9d;14b;17a;18a;	2		2			2		1	40	40
H7301	002	0	1	04	01	H7301_002_0	6	3	OON Supplemental Benefits 14c	10		14c;	2		1	0.00	50.00	2		1	40	40
H7301	002	0	1	04	01	H7301_002_0	6	4	Dental Allowance	10		16a;	2		1	0.00	0.00	2		2		
H7301	006	0	1	04	01	H7301_006_0	4	1	OON Standard Coinsuance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	50	50
H7301	006	0	1	04	01	H7301_006_0	4	2	OON Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H7301	006	0	1	04	01	H7301_006_0	4	3	OON Supplemental Benefits - 14c	10		14c;	2		1	50.00	50.00	2		1	50	50
H7301	007	0	1	04	01	H7301_007_0	7	2	OON Ambulance	01	10a;		2		1	300.00	300.00	2		2		
H7301	007	0	1	04	01	H7301_007_0	7	1	OON Standard Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	50	50
H7301	007	0	1	04	01	H7301_007_0	7	3	OON Supplemental Benefits -14c	10		14c;	2		1	0.00	50.00	2		1	50	50
H7301	008	0	1	04	01	H7301_008_0	7	1	20% OON	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	20	20
H7301	008	0	1	04	01	H7301_008_0	7	2	Ambulance	01	10a;		2		1	100.00	100.00	2		2		
H7301	008	0	1	04	01	H7301_008_0	7	3	OON  Supplemental Benefits 14c	10		14c;	2		1	0.00	50.00	2		1	20	20
H7301	008	0	1	04	01	H7301_008_0	7	4	OON Eyewear & Hearing & Dental	10		16a;17b;18b;	2		1	0.00	0.00	2		2		
H7301	008	0	1	04	01	H7301_008_0	7	5	14a Preventive	01	14a;		2		2			2		1	0	20
H7301	801	0	1	04	01	H7301_801_0	2	1		01	6;14a;		2		2			2		1	0	0
H7301	801	0	1	04	01	H7301_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H7301	803	0	1	04	01	H7301_803_0	2	1		01	6;14a;		2		2			2		1	0	0
H7301	803	0	1	04	01	H7301_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H7522	001	0	1	04	01	H7522_001_0	7	1	20% coinsurance Group	11	3-1;3-2;3-3;6;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;10a;11a;11b;11c;12;14a;15;16b;17a;17b;18a;	7b;7f;9d;16a;17a;18a;	2		2			2		1	20	20
H7522	001	0	1	04	01	H7522_001_0	7	2	50% coinsurance Group	01	5;7e;7h;9c;		2		2			2		1	50	50
H7522	001	0	1	04	01	H7522_001_0	7	3	50% Coinsurance With Max	10		17b;	2		2			2		1	50	50
H7522	001	0	1	04	01	H7522_001_0	7	4	$O coinsurance Group with limits	10		18b;	2		2			2		2		
H7522	001	0	1	04	01	H7522_001_0	7	5	0% Coinsurance Group	11	14d;14e;	13b;14c;	2		2			2		2		
H7522	801	0	1	04	01	H7522_801_0	5	1		01	6;14a;		2		2			2		1	0	0
H7522	801	0	1	04	01	H7522_801_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H7522	802	0	1	04	01	H7522_802_0	5	1		01	6;14a;		2		2			2		1	0	0
H7522	802	0	1	04	01	H7522_802_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H7522	803	0	1	04	01	H7522_803_0	5	1		01	6;14a;		2		2			2		1	0	0
H7522	803	0	1	04	01	H7522_803_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H7728	002	0	1	04	01	H7728_002_0	9	3	40% coinsurance	11	3-1;3-2;3-3;5;6;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;	14b;	2		2			2		1	40	40
H7728	002	0	1	04	01	H7728_002_0	9	4	$50 copayment	01	7a;7g;		2		1	50.00	50.00	2		2		
H7728	002	0	1	04	01	H7728_002_0	9	5	20% Coinsurance	11	12;	16a;	2		2			2		1	20	20
H7728	002	0	1	04	01	H7728_002_0	9	6	Ambulance	01	10a;		2		1	250.00	250.00	2		1	20	20
H7728	002	0	1	04	01	H7728_002_0	9	1	$0	11	9d;16b;17b;	9d;14c;17a;	2		1	0.00	0.00	2		2		
H7728	002	0	1	04	01	H7728_002_0	9	2	$65 copayment	01	7b;7c;7d;7e;7f;7h;7i;		2		1	65.00	65.00	2		2		
H7728	801	0	1	04	01	H7728_801_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H7728	801	0	1	04	01	H7728_801_0	4	1		01	6;14a;		2		2			2		1	0	0
H7728	802	0	1	04	01	H7728_802_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H7728	802	0	1	04	01	H7728_802_0	4	1		01	6;14a;		2		2			2		1	0	0
H7728	803	0	1	04	01	H7728_803_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H7728	803	0	1	04	01	H7728_803_0	4	1		01	6;14a;		2		2			2		1	0	0
H7787	001	0	1	04	01	H7787_001_0	5	5	$40-60 Copay	01	7g;14a;14d;14e;18a;		2		1	40.00	60.00	2		2		
H7787	001	0	1	04	01	H7787_001_0	5	4	$50 Copay/20% Coinsurance	01	10a;		2		1	50.00	50.00	2		1	20	20
H7787	001	0	1	04	01	H7787_001_0	5	3	$60 Copay	01	7b;7c;7d;7f;7i;		2		1	60.00	60.00	2		2		
H7787	001	0	1	04	01	H7787_001_0	5	2	$40 Copay	01	6;7a;		2		1	40.00	40.00	2		2		
H7787	001	0	1	04	01	H7787_001_0	5	10	0%-30% Coinsurance	10		17b;	2		2			2		1	0	30
H7787	001	0	1	04	01	H7787_001_0	5	1	50% Coinsurance	11	3-1;3-2;3-3;5;7e;7h;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;	9d;16a;18a;18b;	2		2			2		1	50	50
H7787	001	0	1	04	01	H7787_001_0	5	6	$0-$60 Copay	11	17a;	17a;	2		1	0.00	60.00	2		2		
H7787	001	0	1	04	01	H7787_001_0	5	9	30% Coinsurance	01	15;16b;		2		2			2		1	30	30
H7787	001	0	1	04	01	H7787_001_0	5	8	$0 Copay	10		14c;	2		2			2		2		
H7787	001	0	1	04	01	H7787_001_0	5	7	0%-30% Coinsurance	01	17b;		2		2			2		1	0	30
H7787	002	0	1	04	01	H7787_002_0	5	1	30% Coinsurance	11	3-1;3-2;3-3;5;7e;7h;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;16b;	9d;	2		2			2		1	30	30
H7787	002	0	1	04	01	H7787_002_0	5	10	50% Coinsurance	10		16a;18a;18b;	2		2			2		1	50	50
H7787	002	0	1	04	01	H7787_002_0	5	2	$40 Copay	01	6;7a;		2		1	40.00	40.00	2		2		
H7787	002	0	1	04	01	H7787_002_0	5	3	$60 Copay	01	7b;7c;7d;7f;7i;		2		1	60.00	60.00	2		2		
H7787	002	0	1	04	01	H7787_002_0	5	9	$0 Copay	10		14c;	2		2			2		2		
H7787	002	0	1	04	01	H7787_002_0	5	5	$40-$60 Copay	01	7g;14a;14d;14e;18a;		2		1	40.00	60.00	2		2		
H7787	002	0	1	04	01	H7787_002_0	5	8	25% Coinsurance	01	15;		2		2			2		1	25	25
H7787	002	0	1	04	01	H7787_002_0	5	7	0%-30%	01	17b;		2		2			2		1	0	30
H7787	002	0	1	04	01	H7787_002_0	5	6	$0-$60	01	17a;		2		1	0.00	60.00	2		2		
H7787	002	0	1	04	01	H7787_002_0	5	4	$50 Copay/20% Coinsurance	01	10a;		2		1	50.00	50.00	2		1	20	20
H7917	008	0	1	04	01	H7917_008_0	4	1	50% Cost Share Group	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14a;15;16b;		2		2			2		1	50	50
H7917	008	0	1	04	01	H7917_008_0	4	2	Ambulance	01	10a;		2		1	150.00	150.00	2		2		
H7917	008	0	1	04	01	H7917_008_0	4	3	$0 Cost Share	11	9d;17b;	9d;14c;17b;	2		2			2		2		
H7917	008	0	1	04	01	H7917_008_0	4	4	$30 Cost Share	11	17a;	17a;	2		1	30.00	30.00	2		2		
H7917	008	0	1	04	01	H7917_008_0	4	5	20% Cost Share	01	11c;12;14d;14e;		2		2			2		1	20	20
H7917	008	0	1	04	01	H7917_008_0	4	6	$15 Copay	11	18a;	18a;	2		1	15.00	15.00	2		2		
H7917	009	0	1	04	01	H7917_009_0	4	1	50% Cost Share Group	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14a;15;16b;		2		2			2		1	50	50
H7917	009	0	1	04	01	H7917_009_0	4	2	Ambulance	01	10a;		2		1	150.00	150.00	2		2		
H7917	009	0	1	04	01	H7917_009_0	4	3	$0 Cost Share	11	9d;17b;	9d;14c;17b;	2		2			2		2		
H7917	009	0	1	04	01	H7917_009_0	4	4	$30 Cost Share	11	17a;	17a;	2		1	30.00	30.00	2		2		
H7917	009	0	1	04	01	H7917_009_0	4	5	20% Cost Share	01	11c;12;14d;14e;		2		2			2		1	20	20
H7917	009	0	1	04	01	H7917_009_0	4	6	$15 Copay	11	18a;	18a;	2		1	15.00	15.00	2		2		
H7917	010	0	1	04	01	H7917_010_0	4	3	$0 Cost Share	11	9d;17b;	9d;14c;17b;	2		2			2		2		
H7917	010	0	1	04	01	H7917_010_0	4	4	$30 Cost Share	11	17a;	17a;	2		1	30.00	30.00	2		2		
H7917	010	0	1	04	01	H7917_010_0	4	5	20% Cost Share	01	11c;12;14d;14e;		2		2			2		1	20	20
H7917	010	0	1	04	01	H7917_010_0	4	6	$15 Copay	11	18a;	18a;	2		1	15.00	15.00	2		2		
H7917	010	0	1	04	01	H7917_010_0	4	1	50% Cost Share Group	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14a;15;16b;		2		2			2		1	50	50
H7917	010	0	1	04	01	H7917_010_0	4	2	Ambulance	01	10a;		2		1	150.00	150.00	2		2		
H7917	011	0	1	04	01	H7917_011_0	5	1	50% Cost Share Group	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14a;15;16b;		2		2			2		1	50	50
H7917	011	0	1	04	01	H7917_011_0	5	2	Ambulance	01	10a;		2		1	150.00	150.00	2		2		
H7917	011	0	1	04	01	H7917_011_0	5	3	$0 Cost Share	11	9d;17b;	9d;14c;17b;	2		2			2		2		
H7917	011	0	1	04	01	H7917_011_0	5	4	$30 Cost Share	11	17a;	17a;	2		1	30.00	30.00	2		2		
H7917	011	0	1	04	01	H7917_011_0	5	5	20% Cost Share	01	11c;12;14d;14e;		2		2			2		1	20	20
H7917	011	0	1	04	01	H7917_011_0	5	6	$15 Copay	11	18a;	18a;	2		1	15.00	15.00	2		2		
H7917	012	0	1	04	01	H7917_012_0	6	5	20% Cost Share	01	11c;12;14d;14e;		2		2			2		1	20	20
H7917	012	0	1	04	01	H7917_012_0	6	4	$40 Cost Share	11	17a;	17a;	2		1	40.00	40.00	2		2		
H7917	012	0	1	04	01	H7917_012_0	6	3	$0 Cost Share	11	9d;17b;	9d;14c;17b;	2		2			2		2		
H7917	012	0	1	04	01	H7917_012_0	6	2	Ambulance	01	10a;		2		1	150.00	150.00	2		2		
H7917	012	0	1	04	01	H7917_012_0	6	1	50% Cost Share Group	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14a;15;16b;		2		2			2		1	50	50
H7917	012	0	1	04	01	H7917_012_0	6	6	$15 Copay	11	18a;	18a;	2		1	15.00	15.00	2		2		
H7917	013	0	1	04	01	H7917_013_0	4	1	50% Cost Share Group	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14a;15;16b;		2		2			2		1	50	50
H7917	013	0	1	04	01	H7917_013_0	4	2	Ambulance	01	10a;		2		1	150.00	150.00	2		2		
H7917	013	0	1	04	01	H7917_013_0	4	3	$0 Cost Share	11	9d;17b;	9d;14c;17b;	2		2			2		2		
H7917	013	0	1	04	01	H7917_013_0	4	4	$40 Cost Share	11	17a;	17a;	2		1	40.00	40.00	2		2		
H7917	013	0	1	04	01	H7917_013_0	4	5	20% Cost Share	01	11c;12;14d;14e;		2		2			2		1	20	20
H7917	013	0	1	04	01	H7917_013_0	4	6	$15 Copay	11	18a;	18a;	2		1	15.00	15.00	2		2		
H7917	014	0	1	04	01	H7917_014_0	5	1	50% Cost Share Group	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14a;15;16b;		2		2			2		1	50	50
H7917	014	0	1	04	01	H7917_014_0	5	2	Ambulance	01	10a;		2		1	150.00	150.00	2		2		
H7917	014	0	1	04	01	H7917_014_0	5	3	$0 Cost Share	11	9d;17b;	9d;14c;17b;	2		2			2		2		
H7917	014	0	1	04	01	H7917_014_0	5	4	$40 Cost Share	11	17a;	17a;	2		1	40.00	40.00	2		2		
H7917	014	0	1	04	01	H7917_014_0	5	5	20% Cost Share	01	11c;12;14d;14e;		2		2			2		1	20	20
H7917	014	0	1	04	01	H7917_014_0	5	6	$15 Copay	11	18a;	18a;	2		1	15.00	15.00	2		2		
H7917	015	0	1	04	01	H7917_015_0	4	5	20% Cost Share	01	11c;12;14d;14e;		2		2			2		1	20	20
H7917	015	0	1	04	01	H7917_015_0	4	4	$40 Cost Share	11	17a;	17a;	2		1	40.00	40.00	2		2		
H7917	015	0	1	04	01	H7917_015_0	4	3	$0 Cost Share	11	9d;17b;	9d;14c;17b;	2		2			2		2		
H7917	015	0	1	04	01	H7917_015_0	4	2	Ambulance	01	10a;		2		1	150.00	150.00	2		2		
H7917	015	0	1	04	01	H7917_015_0	4	1	50% Cost Share Group	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14a;15;16b;		2		2			2		1	50	50
H7917	015	0	1	04	01	H7917_015_0	4	6	$15 Copay	11	18a;	18a;	2		1	15.00	15.00	2		2		
H7917	030	0	1	04	01	H7917_030_0	4	2	Ambulance	01	10a;		2		1	250.00	250.00	2		2		
H7917	030	0	1	04	01	H7917_030_0	4	1	50% Cost Share Group	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14a;15;16b;		2		2			2		1	50	50
H7917	030	0	1	04	01	H7917_030_0	4	3	$0 Cost Share	11	9d;17b;	9d;14c;17b;	2		2			2		2		
H7917	030	0	1	04	01	H7917_030_0	4	4	$40 Cost Share	11	17a;	17a;	2		1	40.00	40.00	2		2		
H7917	030	0	1	04	01	H7917_030_0	4	5	20% Cost Share	01	11c;12;14d;14e;		2		2			2		1	20	20
H7917	030	0	1	04	01	H7917_030_0	4	6	$15 Copay	11	18a;	18a;	2		1	15.00	15.00	2		2		
H7917	031	0	1	04	01	H7917_031_0	5	1	50% Cost Share Group	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14a;15;16b;		2		2			2		1	50	50
H7917	031	0	1	04	01	H7917_031_0	5	2	Ambulance	01	10a;		2		1	250.00	250.00	2		2		
H7917	031	0	1	04	01	H7917_031_0	5	3	$0 Cost Share	11	9d;17b;	9d;14c;17b;	2		2			2		2		
H7917	031	0	1	04	01	H7917_031_0	5	4	$40 Cost Share	11	17a;	17a;	2		1	40.00	40.00	2		2		
H7917	031	0	1	04	01	H7917_031_0	5	5	20% Cost Share	01	11c;12;14d;14e;		2		2			2		1	20	20
H7917	031	0	1	04	01	H7917_031_0	5	6	$15 Copay	11	18a;	18a;	2		1	15.00	15.00	2		2		
H7917	032	0	1	04	01	H7917_032_0	5	2	Ambulance	01	10a;		2		1	250.00	250.00	2		2		
H7917	032	0	1	04	01	H7917_032_0	5	1	50% Cost Share Group	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14a;15;16b;		2		2			2		1	50	50
H7917	032	0	1	04	01	H7917_032_0	5	3	$0 Cost Share	11	9d;17b;	9d;14c;17b;	2		2			2		2		
H7917	032	0	1	04	01	H7917_032_0	5	6	$15 Copay	11	18a;	18a;	2		1	15.00	15.00	2		2		
H7917	032	0	1	04	01	H7917_032_0	5	5	20% Cost Share	01	11c;12;14d;14e;		2		2			2		1	20	20
H7917	032	0	1	04	01	H7917_032_0	5	4	$40 Cost Share	11	17a;	17a;	2		1	40.00	40.00	2		2		
H7917	033	0	1	04	01	H7917_033_0	5	1	50% Cost Share Group	01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;14a;15;16b;		2		2			2		1	50	50
H7917	033	0	1	04	01	H7917_033_0	5	2	Ambulance	01	10a;		2		1	250.00	250.00	2		2		
H7917	033	0	1	04	01	H7917_033_0	5	3	$0 Cost Share	11	9d;17b;	9d;14c;17b;	2		2			2		2		
H7917	033	0	1	04	01	H7917_033_0	5	4	$40 Cost Share	11	17a;	17a;	2		1	40.00	40.00	2		2		
H7917	033	0	1	04	01	H7917_033_0	5	5	20% Cost Share	01	11c;12;14d;14e;		2		2			2		1	20	20
H7917	033	0	1	04	01	H7917_033_0	5	6	$15 Copay	11	18a;	18a;	2		1	15.00	15.00	2		2		
H7917	801	0	1	04	01	H7917_801_0	1	1		01	6;14a;		2		2			2		1	0	0
H7917	801	0	1	04	01	H7917_801_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H7917	802	0	1	04	01	H7917_802_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H7917	802	0	1	04	01	H7917_802_0	1	1		01	6;14a;		2		2			2		1	0	0
H7917	803	0	1	04	01	H7917_803_0	1	1		01	6;14a;		2		2			2		1	0	0
H7917	803	0	1	04	01	H7917_803_0	1	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H7971	001	0	1	04	01	H7971_001_0	10	1		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;17a;	2		2			2		1	35	35
H7971	001	0	1	04	01	H7971_001_0	10	2		10		17b;	2		2			2		2		
H7971	801	0	1	04	01	H7971_801_0	7	1		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;17a;	2		2			2		1	35	35
H7971	801	0	1	04	01	H7971_801_0	7	2		10		17b;	2		2			2		2		
H7971	802	0	1	04	01	H7971_802_0	6	1		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	9d;17a;	2		2			2		1	35	35
H7971	802	0	1	04	01	H7971_802_0	6	2		10		17b;	2		2			2		2		
H8064	002	0	1	04	01	H8064_002_0	9	1	20 PCT COINSURANCE	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;15;16b;17a;17b;18a;	17a;	2		2			2		1	20	20
H8064	002	0	1	04	01	H8064_002_0	9	2	0 COPAY	11	14a;14d;14e;	14b;	2		1	0.00	0.00	2		2		
H8064	002	0	1	04	01	H8064_002_0	9	3	15 PCT COINSURANCE	01	6;		2		2			2		1	15	15
H8064	002	0	1	04	01	H8064_002_0	9	4	150 Copay	01	10a;		2		1	150.00	150.00	2		2		
H8064	002	0	1	04	01	H8064_002_0	9	5	Supplemental	10		14c;	1	300.00	2			2		2		
H8091	002	0	1	04	01	H8091_002_0	9	1	All Other - 30% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;16b;17a;17b;18a;	14b;	2		2			2		1	30	30
H8091	002	0	1	04	01	H8091_002_0	9	3	Ambulance	01	10a;		2		1	350.00	350.00	2		2		
H8091	002	0	1	04	01	H8091_002_0	9	2	Zero Coinsurance/Copay	11	14e;	9d;14c;	2		2			2		2		
H8091	004	0	1	04	01	H8091_004_0	8	2	Zero Coinsurance/Copay	11	14e;	9d;14c;	2		2			2		2		
H8091	004	0	1	04	01	H8091_004_0	8	1	All Other - 30% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14a;14d;15;16b;17a;17b;18a;	14b;	2		2			2		1	30	30
H8091	004	0	1	04	01	H8091_004_0	8	3	Ambulance	01	10a;		2		1	350.00	350.00	2		2		
H8145	003	0	1	09	04	H8145_003_0	4	12		01	8b1;				1	45.00	295.00	2		2		
H8145	003	0	1	09	04	H8145_003_0	4	11		01	5;7e;7h;				1	40.00	40.00	2		2		
H8145	003	0	1	09	04	H8145_003_0	4	14		11	11a;11b;11c;12;15;	13c;14c;	2		2			2		1	20	20
H8145	003	0	1	09	04	H8145_003_0	4	15		10		13b;	1	15.00	2			2		1	50	50
H8145	003	0	1	09	04	H8145_003_0	4	2		01	8a1;8a2;17a;				1	0.00	105.00	2		2		
H8145	003	0	1	09	04	H8145_003_0	4	3		01	9c;				1	40.00	105.00	2		2		
H8145	003	0	1	09	04	H8145_003_0	4	4		01	8b3;				1	15.00	105.00	2		2		
H8145	003	0	1	09	04	H8145_003_0	4	5		01	3-1;3-2;3-3;7a;7c;7i;				1	15.00	40.00	2		2		
H8145	003	0	1	09	04	H8145_003_0	4	6		01	7b;				1	20.00	20.00	2		2		
H8145	003	0	1	09	04	H8145_003_0	4	7		01	9b;				1	245.00	245.00	2		2		
H8145	003	0	1	09	04	H8145_003_0	4	8		01	17b;				1	25.00	25.00	2		2		
H8145	003	0	1	09	04	H8145_003_0	4	9		01	9a;				1	295.00	295.00	2		2		
H8145	003	0	1	09	04	H8145_003_0	4	13		01	7d;7f;7g;8b2;16b;18a;				1	45.00	45.00	2		1	20	20
H8145	003	0	1	09	04	H8145_003_0	4	10		01	10a;				1	300.00	300.00	2		2		
H8145	003	0	1	09	04	H8145_003_0	4	1		11	6;9d;14a;14d;14e;	9d;13d;14b;	2		1	0.00	0.00	2		2		
H8145	004	0	1	09	04	H8145_004_0	3	12		01	8b1;				1	45.00	295.00	2		2		
H8145	004	0	1	09	04	H8145_004_0	3	1		11	6;9d;14a;14d;14e;	9d;13d;14b;	2		1	0.00	0.00	2		2		
H8145	004	0	1	09	04	H8145_004_0	3	14		11	11a;11b;11c;12;15;	13c;14c;	2		2			2		1	20	20
H8145	004	0	1	09	04	H8145_004_0	3	15		10		13b;	1	15.00	2			2		1	50	50
H8145	004	0	1	09	04	H8145_004_0	3	2		01	8a1;8a2;17a;				1	0.00	105.00	2		2		
H8145	004	0	1	09	04	H8145_004_0	3	3		01	9c;				1	40.00	105.00	2		2		
H8145	004	0	1	09	04	H8145_004_0	3	4		01	8b3;				1	15.00	105.00	2		2		
H8145	004	0	1	09	04	H8145_004_0	3	5		01	3-1;3-2;3-3;7a;7c;7i;				1	15.00	40.00	2		2		
H8145	004	0	1	09	04	H8145_004_0	3	6		01	7b;				1	20.00	20.00	2		2		
H8145	004	0	1	09	04	H8145_004_0	3	7		01	9b;				1	245.00	245.00	2		2		
H8145	004	0	1	09	04	H8145_004_0	3	8		01	17b;				1	25.00	25.00	2		2		
H8145	004	0	1	09	04	H8145_004_0	3	9		01	9a;				1	295.00	295.00	2		2		
H8145	004	0	1	09	04	H8145_004_0	3	13		01	7d;7f;7g;8b2;16b;18a;				1	45.00	45.00	2		1	20	20
H8145	004	0	1	09	04	H8145_004_0	3	10		01	10a;				1	300.00	300.00	2		2		
H8145	004	0	1	09	04	H8145_004_0	3	11		01	5;7e;7h;				1	40.00	40.00	2		2		
H8145	006	0	1	09	04	H8145_006_0	3	12		01	9a;				2			2		1	25	25
H8145	006	0	1	09	04	H8145_006_0	3	1		11	9d;14a;14d;14e;	9d;13d;14b;17a;	2		1	0.00	0.00	2		2		
H8145	006	0	1	09	04	H8145_006_0	3	14		10		13b;	1	15.00	2			2		1	50	50
H8145	006	0	1	09	04	H8145_006_0	3	2		01	8a2;17a;				1	0.00	45.00	2		2		
H8145	006	0	1	09	04	H8145_006_0	3	3		01	8a1;				1	0.00	95.00	2		2		
H8145	006	0	1	09	04	H8145_006_0	3	4		01	3-1;3-2;7a;7b;17b;				1	15.00	15.00	2		2		
H8145	006	0	1	09	04	H8145_006_0	3	5		01	8b3;				1	15.00	95.00	2		2		
H8145	006	0	1	09	04	H8145_006_0	3	6		01	7c;7e;7h;7i;				1	40.00	40.00	2		2		
H8145	006	0	1	09	04	H8145_006_0	3	7		01	9c;				1	40.00	95.00	2		2		
H8145	006	0	1	09	04	H8145_006_0	3	8		01	3-3;7d;7f;7g;16b;18a;				1	45.00	45.00	2		2		
H8145	006	0	1	09	04	H8145_006_0	3	9		01	5;				1	55.00	55.00	2		2		
H8145	006	0	1	09	04	H8145_006_0	3	13		10		13c;14c;16a;16b;	2		2			2		1	50	50
H8145	006	0	1	09	04	H8145_006_0	3	10		01	6;8b2;9b;10a;11a;11b;11c;12;15;				2			2		1	20	20
H8145	006	0	1	09	04	H8145_006_0	3	11		01	8b1;				1	15.00	95.00	2		1	20	25
H8145	008	0	1	09	04	H8145_008_0	3	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b3;9a;9b;9c;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;	13c;13d;14b;14c;	2		2			2		1	50	50
H8145	008	0	1	09	04	H8145_008_0	3	5		10		13b;	1	15.00	2			2		1	50	50
H8145	008	0	1	09	04	H8145_008_0	3	3		01	11a;				2			2		1	40	40
H8145	008	0	1	09	04	H8145_008_0	3	2		01	8b2;10a;12;				2			2		1	20	20
H8145	008	0	1	09	04	H8145_008_0	3	1		11	9d;	9d;17a;	2		1	0.00	0.00	2		2		
H8145	011	0	1	09	04	H8145_011_0	4	1		11	6;9d;14a;14d;14e;	9d;13d;14b;17a;	2		1	0.00	0.00	2		2		
H8145	011	0	1	09	04	H8145_011_0	4	9		01	10a;				1	300.00	300.00	2		2		
H8145	011	0	1	09	04	H8145_011_0	4	11		01	8b1;				1	45.00	295.00	2		2		
H8145	011	0	1	09	04	H8145_011_0	4	12		01	7d;7f;7g;16b;17b;18a;				1	45.00	45.00	2		2		
H8145	011	0	1	09	04	H8145_011_0	4	13		11	11a;11b;11c;12;15;	13c;14c;	2		2			2		1	20	20
H8145	011	0	1	09	04	H8145_011_0	4	14		01	8b2;				1	45.00	45.00	2		1	20	20
H8145	011	0	1	09	04	H8145_011_0	4	15		10		13b;	1	15.00	2			2		1	50	50
H8145	011	0	1	09	04	H8145_011_0	4	2		01	8a1;8a2;17a;				1	0.00	105.00	2		2		
H8145	011	0	1	09	04	H8145_011_0	4	3		01	9c;				1	40.00	105.00	2		2		
H8145	011	0	1	09	04	H8145_011_0	4	4		01	8b3;				1	20.00	105.00	2		2		
H8145	011	0	1	09	04	H8145_011_0	4	5		01	3-1;3-2;3-3;7a;7b;				1	20.00	20.00	2		2		
H8145	011	0	1	09	04	H8145_011_0	4	6		01	7c;7i;				1	20.00	40.00	2		2		
H8145	011	0	1	09	04	H8145_011_0	4	7		01	9b;				1	265.00	265.00	2		2		
H8145	011	0	1	09	04	H8145_011_0	4	8		01	9a;				1	295.00	295.00	2		2		
H8145	011	0	1	09	04	H8145_011_0	4	10		01	5;7e;7h;				1	40.00	40.00	2		2		
H8145	020	0	1	09	04	H8145_020_0	3	4		01	14a;				2			2		1	0	30
H8145	020	0	1	09	04	H8145_020_0	3	3		01	10a;				1	300.00	300.00	2		2		
H8145	020	0	1	09	04	H8145_020_0	3	6		01	15;				2			2		1	20	30
H8145	020	0	1	09	04	H8145_020_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H8145	020	0	1	09	04	H8145_020_0	3	8		10		13c;14c;	2		2			2		1	50	50
H8145	020	0	1	09	04	H8145_020_0	3	9		10		13b;	1	20.00	2			2		1	50	50
H8145	020	0	1	09	04	H8145_020_0	3	5		01	12;				2			2		1	20	20
H8145	020	0	1	09	04	H8145_020_0	3	2		01	17b;				1	25.00	25.00	2		2		
H8145	020	0	1	09	04	H8145_020_0	3	1		11	9d;	9d;17a;	2		1	0.00	0.00	2		2		
H8145	021	0	1	09	04	H8145_021_0	4	4		01	14a;				2			2		1	0	30
H8145	021	0	1	09	04	H8145_021_0	4	5		01	12;				2			2		1	20	20
H8145	021	0	1	09	04	H8145_021_0	4	6		01	15;				2			2		1	20	30
H8145	021	0	1	09	04	H8145_021_0	4	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H8145	021	0	1	09	04	H8145_021_0	4	1		11	9d;	9d;	2		1	0.00	0.00	2		2		
H8145	021	0	1	09	04	H8145_021_0	4	9		10		13b;	1	20.00	2			2		1	50	50
H8145	021	0	1	09	04	H8145_021_0	4	3		01	10a;				1	300.00	300.00	2		2		
H8145	021	0	1	09	04	H8145_021_0	4	2		01	17b;				1	25.00	25.00	2		2		
H8145	021	0	1	09	04	H8145_021_0	4	8		10		13c;14c;16a;16b;	2		2			2		1	50	50
H8145	032	0	1	09	04	H8145_032_0	4	1		11	6;9d;14d;	9d;14b;	2		1	0.00	0.00	2		2		
H8145	032	0	1	09	04	H8145_032_0	4	9		11	14a;14e;	13d;	2		1	0.00	0.00	2		1	30	30
H8145	032	0	1	09	04	H8145_032_0	4	11		01	3-1;3-2;3-3;7c;7i;				1	20.00	20.00	2		1	30	30
H8145	032	0	1	09	04	H8145_032_0	4	12		01	8b3;				1	20.00	40.00	2		1	30	30
H8145	032	0	1	09	04	H8145_032_0	4	13		01	8b1;				1	40.00	295.00	2		1	30	30
H8145	032	0	1	09	04	H8145_032_0	4	14		10		13b;	1	15.00	2			2		1	50	50
H8145	032	0	1	09	04	H8145_032_0	4	15		10		16a;16b;	2		2			2		1	50	80
H8145	032	0	1	09	04	H8145_032_0	4	2		01	17a;				1	0.00	40.00	2		2		
H8145	032	0	1	09	04	H8145_032_0	4	3		01	7a;7b;17b;				1	20.00	20.00	2		2		
H8145	032	0	1	09	04	H8145_032_0	4	4		01	9b;				1	265.00	265.00	2		2		
H8145	032	0	1	09	04	H8145_032_0	4	5		01	10a;				1	300.00	300.00	2		2		
H8145	032	0	1	09	04	H8145_032_0	4	6		01	5;7d;7e;7f;7g;7h;9c;16b;18a;				1	40.00	40.00	2		1	30	30
H8145	032	0	1	09	04	H8145_032_0	4	7		11	11a;11b;11c;12;15;	13c;14c;	2		2			2		1	20	20
H8145	032	0	1	09	04	H8145_032_0	4	8		01	8b2;9a;				2			2		1	30	30
H8145	032	0	1	09	04	H8145_032_0	4	10		01	8a1;8a2;				1	0.00	40.00	2		1	30	30
H8145	042	0	1	09	04	H8145_042_0	2	1		11	6;9d;14a;14d;14e;	9d;13d;14b;	2		1	0.00	0.00	2		2		
H8145	042	0	1	09	04	H8145_042_0	2	9		01	9a;				1	295.00	295.00	2		2		
H8145	042	0	1	09	04	H8145_042_0	2	11		01	5;7e;7h;				1	40.00	40.00	2		2		
H8145	042	0	1	09	04	H8145_042_0	2	12		01	8b1;				1	45.00	295.00	2		2		
H8145	042	0	1	09	04	H8145_042_0	2	13		01	7d;7f;7g;8b2;16b;18a;				1	45.00	45.00	2		1	20	20
H8145	042	0	1	09	04	H8145_042_0	2	14		11	11a;11b;11c;12;15;	13c;14c;	2		2			2		1	20	20
H8145	042	0	1	09	04	H8145_042_0	2	15		10		13b;	1	15.00	2			2		1	50	50
H8145	042	0	1	09	04	H8145_042_0	2	2		01	8a1;8a2;17a;				1	0.00	105.00	2		2		
H8145	042	0	1	09	04	H8145_042_0	2	3		01	9c;				1	40.00	105.00	2		2		
H8145	042	0	1	09	04	H8145_042_0	2	4		01	8b3;				1	15.00	105.00	2		2		
H8145	042	0	1	09	04	H8145_042_0	2	5		01	3-1;3-2;3-3;7a;7c;7i;				1	15.00	40.00	2		2		
H8145	042	0	1	09	04	H8145_042_0	2	6		01	7b;				1	20.00	20.00	2		2		
H8145	042	0	1	09	04	H8145_042_0	2	7		01	9b;				1	245.00	245.00	2		2		
H8145	042	0	1	09	04	H8145_042_0	2	8		01	17b;				1	25.00	25.00	2		2		
H8145	042	0	1	09	04	H8145_042_0	2	10		01	10a;				1	300.00	300.00	2		2		
H8145	050	0	1	09	04	H8145_050_0	2	5		01	8a1;				1	0.00	0.00	2		1	20	20
H8145	050	0	1	09	04	H8145_050_0	2	6		10		13c;14c;	2		2			2		1	50	50
H8145	050	0	1	09	04	H8145_050_0	2	7		10		13b;	1	20.00	2			2		1	50	50
H8145	050	0	1	09	04	H8145_050_0	2	1		11	6;9d;14d;14e;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H8145	050	0	1	09	04	H8145_050_0	2	2		11	14a;	13d;14b;	2		2			2		1	0	0
H8145	050	0	1	09	04	H8145_050_0	2	3		01	8a2;17a;				2			2		1	0	20
H8145	050	0	1	09	04	H8145_050_0	2	4		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8b1;8b2;8b3;9a;9b;9c;10a;11a;11b;11c;12;15;16b;17b;18a;				2			2		1	20	20
H8145	051	0	1	09	04	H8145_051_0	3	1		11	6;9d;14d;14e;	9d;17a;17b;	2		1	0.00	0.00	2		2		
H8145	051	0	1	09	04	H8145_051_0	3	2		11	14a;	13d;14b;	2		2			2		1	0	0
H8145	051	0	1	09	04	H8145_051_0	3	3		01	8a2;17a;				2			2		1	0	20
H8145	051	0	1	09	04	H8145_051_0	3	5		01	8a1;				1	0.00	0.00	2		1	20	20
H8145	051	0	1	09	04	H8145_051_0	3	6		10		13c;14c;	2		2			2		1	50	50
H8145	051	0	1	09	04	H8145_051_0	3	7		10		13b;	1	20.00	2			2		1	50	50
H8145	051	0	1	09	04	H8145_051_0	3	4		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8b1;8b2;8b3;9a;9b;9c;10a;11a;11b;11c;12;15;16b;17b;18a;				2			2		1	20	20
H8145	052	0	1	09	04	H8145_052_0	4	11		01	8b1;				1	45.00	270.00	2		2		
H8145	052	0	1	09	04	H8145_052_0	4	10		01	5;7e;7h;				1	40.00	40.00	2		2		
H8145	052	0	1	09	04	H8145_052_0	4	1		11	6;9d;14a;14d;14e;	9d;13d;14b;	2		1	0.00	0.00	2		2		
H8145	052	0	1	09	04	H8145_052_0	4	13		01	9c;				1	40.00	95.00	2		2		
H8145	052	0	1	09	04	H8145_052_0	4	9		01	9a;				1	270.00	270.00	2		2		
H8145	052	0	1	09	04	H8145_052_0	4	8		01	10a;				1	250.00	250.00	2		2		
H8145	052	0	1	09	04	H8145_052_0	4	7		01	17b;				1	25.00	25.00	2		2		
H8145	052	0	1	09	04	H8145_052_0	4	6		01	9b;				1	220.00	220.00	2		2		
H8145	052	0	1	09	04	H8145_052_0	4	5		01	7b;				1	20.00	20.00	2		2		
H8145	052	0	1	09	04	H8145_052_0	4	4		01	8b3;				1	15.00	95.00	2		2		
H8145	052	0	1	09	04	H8145_052_0	4	3		01	3-1;3-2;3-3;7a;7c;7i;				1	15.00	40.00	2		2		
H8145	052	0	1	09	04	H8145_052_0	4	2		01	8a1;8a2;17a;				1	0.00	95.00	2		2		
H8145	052	0	1	09	04	H8145_052_0	4	12		01	7d;7f;7g;8b2;16b;18a;				1	45.00	45.00	2		1	20	20
H8145	052	0	1	09	04	H8145_052_0	4	14		11	11a;11b;11c;12;15;	13c;14c;	2		2			2		1	20	20
H8145	052	0	1	09	04	H8145_052_0	4	15		10		13b;	1	20.00	2			2		1	50	50
H8145	053	0	1	09	04	H8145_053_0	3	1		11	6;9d;14a;14d;14e;	9d;13d;14b;	2		1	0.00	0.00	2		2		
H8145	053	0	1	09	04	H8145_053_0	3	10		01	8b1;				1	40.00	265.00	2		2		
H8145	053	0	1	09	04	H8145_053_0	3	11		01	5;7d;7e;7f;7g;7h;16b;18a;				1	40.00	40.00	2		2		
H8145	053	0	1	09	04	H8145_053_0	3	12		01	9c;				1	40.00	90.00	2		2		
H8145	053	0	1	09	04	H8145_053_0	3	13		11	11a;11b;11c;12;15;	13c;14c;	2		2			2		1	20	20
H8145	053	0	1	09	04	H8145_053_0	3	14		01	8b2;				1	40.00	40.00	2		1	20	20
H8145	053	0	1	09	04	H8145_053_0	3	15		10		13b;	1	30.00	2			2		1	50	50
H8145	053	0	1	09	04	H8145_053_0	3	2		01	8a1;8a2;17a;				1	0.00	90.00	2		2		
H8145	053	0	1	09	04	H8145_053_0	3	3		01	3-1;3-2;3-3;7a;7c;7i;				1	15.00	40.00	2		2		
H8145	053	0	1	09	04	H8145_053_0	3	4		01	8b3;				1	15.00	90.00	2		2		
H8145	053	0	1	09	04	H8145_053_0	3	5		01	7b;				1	20.00	20.00	2		2		
H8145	053	0	1	09	04	H8145_053_0	3	6		01	9b;				1	215.00	215.00	2		2		
H8145	053	0	1	09	04	H8145_053_0	3	7		01	17b;				1	25.00	25.00	2		2		
H8145	053	0	1	09	04	H8145_053_0	3	8		01	10a;				1	250.00	250.00	2		2		
H8145	053	0	1	09	04	H8145_053_0	3	9		01	9a;				1	265.00	265.00	2		2		
H8145	055	0	1	09	04	H8145_055_0	2	3		01	9c;				1	40.00	105.00	2		2		
H8145	055	0	1	09	04	H8145_055_0	2	2		01	8a1;8a2;17a;				1	0.00	105.00	2		2		
H8145	055	0	1	09	04	H8145_055_0	2	5		01	3-1;3-2;3-3;7a;7c;7i;				1	15.00	40.00	2		2		
H8145	055	0	1	09	04	H8145_055_0	2	6		01	7b;				1	20.00	20.00	2		2		
H8145	055	0	1	09	04	H8145_055_0	2	7		01	9b;				1	245.00	245.00	2		2		
H8145	055	0	1	09	04	H8145_055_0	2	8		01	17b;				1	25.00	25.00	2		2		
H8145	055	0	1	09	04	H8145_055_0	2	9		01	9a;				1	295.00	295.00	2		2		
H8145	055	0	1	09	04	H8145_055_0	2	1		11	6;9d;14a;14d;14e;	9d;13d;14b;	2		1	0.00	0.00	2		2		
H8145	055	0	1	09	04	H8145_055_0	2	10		01	10a;				1	300.00	300.00	2		2		
H8145	055	0	1	09	04	H8145_055_0	2	11		01	5;7e;7h;				1	40.00	40.00	2		2		
H8145	055	0	1	09	04	H8145_055_0	2	12		01	8b1;				1	45.00	295.00	2		2		
H8145	055	0	1	09	04	H8145_055_0	2	13		01	7d;7f;7g;8b2;16b;18a;				1	45.00	45.00	2		1	20	20
H8145	055	0	1	09	04	H8145_055_0	2	14		11	11a;11b;11c;12;15;	13c;14c;	2		2			2		1	20	20
H8145	055	0	1	09	04	H8145_055_0	2	15		10		13b;	1	20.00	2			2		1	50	50
H8145	055	0	1	09	04	H8145_055_0	2	4		01	8b3;				1	15.00	105.00	2		2		
H8145	061	0	1	09	04	H8145_061_0	3	8		01	8b3;				1	10.00	40.00	2		1	20	25
H8145	061	0	1	09	04	H8145_061_0	3	9		01	8b1;				1	40.00	150.00	2		1	20	25
H8145	061	0	1	09	04	H8145_061_0	3	6		01	7d;7e;7f;7g;7h;16b;18a;				1	40.00	40.00	2		2		
H8145	061	0	1	09	04	H8145_061_0	3	5		01	10a;				1	300.00	300.00	2		2		
H8145	061	0	1	09	04	H8145_061_0	3	4		01	7b;17b;				1	20.00	20.00	2		2		
H8145	061	0	1	09	04	H8145_061_0	3	3		01	7a;				1	10.00	10.00	2		2		
H8145	061	0	1	09	04	H8145_061_0	3	2		01	17a;				1	0.00	40.00	2		2		
H8145	061	0	1	09	04	H8145_061_0	3	15		10		13b;	1	10.00	2			2		1	50	50
H8145	061	0	1	09	04	H8145_061_0	3	14		10		13c;14c;	2		2			2		1	50	50
H8145	061	0	1	09	04	H8145_061_0	3	13		01	3-1;3-2;3-3;				1	40.00	40.00	2		1	25	25
H8145	061	0	1	09	04	H8145_061_0	3	12		01	8a1;8a2;				1	0.00	40.00	2		1	25	25
H8145	061	0	1	09	04	H8145_061_0	3	11		01	9a;9c;				2			2		1	25	25
H8145	061	0	1	09	04	H8145_061_0	3	10		01	7c;7i;8b2;				1	40.00	40.00	2		1	20	25
H8145	061	0	1	09	04	H8145_061_0	3	1		11	6;9d;14a;14d;14e;	9d;13d;14b;17a;	2		1	0.00	0.00	2		2		
H8145	061	0	1	09	04	H8145_061_0	3	7		01	5;9b;11a;11b;11c;12;15;				2			2		1	20	20
H8145	063	0	1	09	04	H8145_063_0	3	9		01	7f;16b;18a;				1	45.00	45.00	2		2		
H8145	063	0	1	09	04	H8145_063_0	3	8		01	8b1;				1	45.00	285.00	2		2		
H8145	063	0	1	09	04	H8145_063_0	3	7		01	5;7e;7h;				1	40.00	40.00	2		2		
H8145	063	0	1	09	04	H8145_063_0	3	6		01	10a;				1	300.00	300.00	2		2		
H8145	063	0	1	09	04	H8145_063_0	3	5		01	9a;				1	285.00	285.00	2		2		
H8145	063	0	1	09	04	H8145_063_0	3	4		01	9b;				1	235.00	235.00	2		2		
H8145	063	0	1	09	04	H8145_063_0	3	3		01	3-1;3-2;3-3;7a;7b;7c;7i;8b3;				1	20.00	95.00	2		2		
H8145	063	0	1	09	04	H8145_063_0	3	15		10		13b;	1	15.00	2			2		1	50	50
H8145	063	0	1	09	04	H8145_063_0	3	14		10		13c;14c;	2		2			2		1	50	50
H8145	063	0	1	09	04	H8145_063_0	3	13		01	7d;7g;8b2;				1	45.00	45.00	2		1	20	20
H8145	063	0	1	09	04	H8145_063_0	3	12		01	8a1;				1	0.00	95.00	2		1	20	20
H8145	063	0	1	09	04	H8145_063_0	3	11		01	11a;11b;11c;12;15;				2			2		1	20	20
H8145	063	0	1	09	04	H8145_063_0	3	10		01	9c;				1	40.00	95.00	2		2		
H8145	063	0	1	09	04	H8145_063_0	3	1		11	6;9d;14a;14d;14e;17b;	9d;13d;14b;	2		1	0.00	0.00	2		2		
H8145	063	0	1	09	04	H8145_063_0	3	2		01	8a2;17a;				1	0.00	95.00	2		2		
H8145	069	0	1	09	04	H8145_069_0	4	10		01	8b1;				1	45.00	280.00	2		2		
H8145	069	0	1	09	04	H8145_069_0	4	1		11	6;9d;14a;14d;14e;17b;	9d;13d;14b;17a;	2		1	0.00	0.00	2		2		
H8145	069	0	1	09	04	H8145_069_0	4	12		01	9c;				1	40.00	95.00	2		2		
H8145	069	0	1	09	04	H8145_069_0	4	13		01	8b2;11a;11b;11c;12;15;				2			2		1	20	20
H8145	069	0	1	09	04	H8145_069_0	4	14		10		13c;14c;	2		2			2		1	50	50
H8145	069	0	1	09	04	H8145_069_0	4	15		10		13b;	1	15.00	2			2		1	50	50
H8145	069	0	1	09	04	H8145_069_0	4	2		01	8a1;8a2;17a;				1	0.00	95.00	2		2		
H8145	069	0	1	09	04	H8145_069_0	4	3		01	3-1;3-2;3-3;7a;7b;				1	15.00	15.00	2		2		
H8145	069	0	1	09	04	H8145_069_0	4	4		01	7c;7d;7g;7i;				1	15.00	45.00	2		2		
H8145	069	0	1	09	04	H8145_069_0	4	5		01	8b3;				1	15.00	95.00	2		2		
H8145	069	0	1	09	04	H8145_069_0	4	6		01	9b;				1	230.00	230.00	2		2		
H8145	069	0	1	09	04	H8145_069_0	4	7		01	9a;				1	280.00	280.00	2		2		
H8145	069	0	1	09	04	H8145_069_0	4	8		01	10a;				1	300.00	300.00	2		2		
H8145	069	0	1	09	04	H8145_069_0	4	9		01	5;7e;7h;				1	40.00	40.00	2		2		
H8145	069	0	1	09	04	H8145_069_0	4	11		01	7f;16b;18a;				1	45.00	45.00	2		2		
H8145	075	0	1	09	04	H8145_075_0	3	1		11	9d;	9d;17a;	2		1	0.00	0.00	2		2		
H8145	075	0	1	09	04	H8145_075_0	3	2		10		18a;	2		1	35.00	35.00	2		2		
H8145	075	0	1	09	04	H8145_075_0	3	3		01	14a;				2			2		1	0	40
H8145	075	0	1	09	04	H8145_075_0	3	8		10		13b;	1	10.00	2			2		1	50	50
H8145	075	0	1	09	04	H8145_075_0	3	5		01	11a;11b;11c;				2			2		1	25	25
H8145	075	0	1	09	04	H8145_075_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;17b;18a;	13d;14b;	2		2			2		1	40	40
H8145	075	0	1	09	04	H8145_075_0	3	7		10		13c;14c;	2		2			2		1	50	50
H8145	075	0	1	09	04	H8145_075_0	3	4		01	10a;12;15;				2			2		1	20	20
H8145	084	0	1	09	04	H8145_084_0	3	10		10		13c;14c;	2		2			2		1	50	50
H8145	084	0	1	09	04	H8145_084_0	3	11		10		13b;	1	15.00	2			2		1	50	50
H8145	084	0	1	09	04	H8145_084_0	3	2		01	7a;				1	20.00	20.00	2		2		
H8145	084	0	1	09	04	H8145_084_0	3	1		11	9d;	9d;17a;	2		1	0.00	0.00	2		2		
H8145	084	0	1	09	04	H8145_084_0	3	3		01	10a;				1	300.00	300.00	2		2		
H8145	084	0	1	09	04	H8145_084_0	3	9		01	3-1;3-2;3-3;7c;7i;8b1;9c;17a;				1	50.00	50.00	2		1	30	30
H8145	084	0	1	09	04	H8145_084_0	3	5		01	14a;				2			2		1	0	30
H8145	084	0	1	09	04	H8145_084_0	3	6		01	11a;11b;11c;12;15;				2			2		1	20	20
H8145	084	0	1	09	04	H8145_084_0	3	7		11	5;6;8b2;9a;9b;14d;14e;17b;	13d;14b;	2		2			2		1	30	30
H8145	084	0	1	09	04	H8145_084_0	3	8		01	8a1;8a2;8b3;				1	20.00	50.00	2		1	30	30
H8145	084	0	1	09	04	H8145_084_0	3	4		01	7b;7d;7e;7f;7g;7h;16b;18a;				1	50.00	50.00	2		2		
H8145	087	0	1	09	04	H8145_087_0	3	2		01	10a;				1	300.00	300.00	2		2		
H8145	087	0	1	09	04	H8145_087_0	3	3		01	14a;				2			2		1	0	30
H8145	087	0	1	09	04	H8145_087_0	3	4		01	11a;11b;11c;12;15;				2			2		1	20	20
H8145	087	0	1	09	04	H8145_087_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
H8145	087	0	1	09	04	H8145_087_0	3	6		10		13c;14c;16a;	2		2			2		1	50	50
H8145	087	0	1	09	04	H8145_087_0	3	7		10		13b;	1	20.00	2			2		1	50	50
H8145	087	0	1	09	04	H8145_087_0	3	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H8145	089	0	1	09	04	H8145_089_0	3	8		10		13c;14c;	2		2			2		1	50	50
H8145	089	0	1	09	04	H8145_089_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;15;16b;17a;17b;18a;	13d;14b;	2		2			2		1	30	30
H8145	089	0	1	09	04	H8145_089_0	3	6		01	11c;				2			2		1	20	30
H8145	089	0	1	09	04	H8145_089_0	3	5		01	12;				2			2		1	20	20
H8145	089	0	1	09	04	H8145_089_0	3	4		01	11a;				2			2		1	15	15
H8145	089	0	1	09	04	H8145_089_0	3	3		01	14a;				2			2		1	0	30
H8145	089	0	1	09	04	H8145_089_0	3	2		01	10a;				1	300.00	300.00	2		2		
H8145	089	0	1	09	04	H8145_089_0	3	1		11	9d;	9d;	2		1	0.00	0.00	2		2		
H8145	091	0	1	09	04	H8145_091_0	3	8		10		13c;14c;	2		2			2		1	50	50
H8145	091	0	1	09	04	H8145_091_0	3	9		10		13b;	1	10.00	2			2		1	50	50
H8145	091	0	1	09	04	H8145_091_0	3	6		01	11b;				2			2		1	25	25
H8145	091	0	1	09	04	H8145_091_0	3	5		01	11c;				2			2		1	20	25
H8145	091	0	1	09	04	H8145_091_0	3	4		01	10a;11a;12;15;				2			2		1	20	20
H8145	091	0	1	09	04	H8145_091_0	3	3		01	14a;				2			2		1	0	35
H8145	091	0	1	09	04	H8145_091_0	3	2		10		18a;	2		1	35.00	35.00	2		2		
H8145	091	0	1	09	04	H8145_091_0	3	1		11	9d;	9d;17a;	2		1	0.00	0.00	2		2		
H8145	091	0	1	09	04	H8145_091_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;17b;18a;	13d;14b;	2		2			2		1	35	35
H8145	093	0	1	09	04	H8145_093_0	3	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13c;13d;14b;14c;	2		2			2		1	50	50
H8145	093	0	1	09	04	H8145_093_0	3	5		01	11a;				2			2		1	35	35
H8145	093	0	1	09	04	H8145_093_0	3	4		01	12;				2			2		1	20	20
H8145	093	0	1	09	04	H8145_093_0	3	3		01	14a;				2			2		1	0	50
H8145	093	0	1	09	04	H8145_093_0	3	2		01	10a;				1	300.00	300.00	2		2		
H8145	093	0	1	09	04	H8145_093_0	3	7		10		13b;	1	10.00	2			2		1	50	50
H8145	093	0	1	09	04	H8145_093_0	3	1		11	9d;17b;	9d;	2		1	0.00	0.00	2		2		
H8145	097	0	1	09	04	H8145_097_0	2	6		10		13b;	1	10.00	2			2		1	50	50
H8145	097	0	1	09	04	H8145_097_0	2	5		10		13c;14c;	2		2			2		1	50	50
H8145	097	0	1	09	04	H8145_097_0	2	4		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8b1;8b2;8b3;9a;9b;9c;10a;11a;11b;11c;12;15;16b;17b;18a;				2			2		1	20	20
H8145	097	0	1	09	04	H8145_097_0	2	3		01	8a1;8a2;17a;				2			2		1	0	20
H8145	097	0	1	09	04	H8145_097_0	2	2		11	14a;	13d;14b;	2		2			2		1	0	0
H8145	097	0	1	09	04	H8145_097_0	2	1		11	6;9d;14d;14e;	9d;	2		1	0.00	0.00	2		2		
H8145	103	0	1	09	04	H8145_103_0	3	1		11	9d;14d;14e;	9d;13d;14b;17a;	2		1	0.00	0.00	2		2		
H8145	103	0	1	09	04	H8145_103_0	3	2		01	10a;				1	350.00	350.00	2		2		
H8145	103	0	1	09	04	H8145_103_0	3	3		01	14a;				1	0.00	0.00	2		1	0	0
H8145	103	0	1	09	04	H8145_103_0	3	4		01	17a;				2			2		1	0	50
H8145	103	0	1	09	04	H8145_103_0	3	5		01	12;				2			2		1	20	20
H8145	103	0	1	09	04	H8145_103_0	3	6		01	11a;11b;11c;				2			2		1	40	40
H8145	103	0	1	09	04	H8145_103_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;15;16b;17b;18a;	13c;14c;	2		2			2		1	50	50
H8145	103	0	1	09	04	H8145_103_0	3	8		10		13b;	1	25.00	2			2		1	50	50
H8145	108	0	1	09	04	H8145_108_0	2	1		11	9d;	9d;17a;	2		1	0.00	0.00	2		2		
H8145	108	0	1	09	04	H8145_108_0	2	2		01	14a;				2			2		1	0	35
H8145	108	0	1	09	04	H8145_108_0	2	3		01	10a;11a;11b;11c;12;15;				2			2		1	20	20
H8145	108	0	1	09	04	H8145_108_0	2	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;17b;18a;	13d;14b;	2		2			2		1	35	35
H8145	108	0	1	09	04	H8145_108_0	2	5		10		13c;14c;	2		2			2		1	50	50
H8145	108	0	1	09	04	H8145_108_0	2	6		10		13b;	1	10.00	2			2		1	50	50
H8145	120	0	1	09	04	H8145_120_0	2	7		10		13c;14c;16a;	2		2			2		1	50	50
H8145	120	0	1	09	04	H8145_120_0	2	8		10		13b;	1	20.00	2			2		1	50	50
H8145	120	0	1	09	04	H8145_120_0	2	1		11	9d;	9d;17a;	2		1	0.00	0.00	2		2		
H8145	120	0	1	09	04	H8145_120_0	2	2		01	10a;				1	300.00	300.00	2		2		
H8145	120	0	1	09	04	H8145_120_0	2	3		01	14a;				2			2		1	0	40
H8145	120	0	1	09	04	H8145_120_0	2	4		01	11a;12;15;				2			2		1	20	20
H8145	120	0	1	09	04	H8145_120_0	2	5		01	11b;11c;				2			2		1	20	40
H8145	120	0	1	09	04	H8145_120_0	2	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;17b;18a;	13d;14b;	2		2			2		1	40	40
H8145	121	0	1	09	04	H8145_121_0	2	1		11	9d;14d;14e;	9d;17a;	2		1	0.00	0.00	2		2		
H8145	121	0	1	09	04	H8145_121_0	2	2		11	14a;	13d;14b;	2		2			2		1	0	0
H8145	121	0	1	09	04	H8145_121_0	2	3		01	8a1;8a2;17a;				2			2		1	0	20
H8145	121	0	1	09	04	H8145_121_0	2	4		01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8b1;8b2;8b3;9a;9b;9c;10a;11a;11b;11c;12;15;16b;17b;18a;				2			2		1	20	20
H8145	121	0	1	09	04	H8145_121_0	2	5		10		13c;14c;16a;16b;	2		2			2		1	50	50
H8145	121	0	1	09	04	H8145_121_0	2	6		10		13b;	1	25.00	2			2		1	50	50
H8145	122	0	1	09	04	H8145_122_0	3	2		01	10a;				1	300.00	300.00	2		2		
H8145	122	0	1	09	04	H8145_122_0	3	1		11	9d;	9d;17a;	2		1	0.00	0.00	2		2		
H8145	122	0	1	09	04	H8145_122_0	3	3		01	14a;				1	0.00	0.00	2		1	0	40
H8145	122	0	1	09	04	H8145_122_0	3	4		01	12;				2			2		1	20	20
H8145	122	0	1	09	04	H8145_122_0	3	5		01	15;				2			2		1	20	40
H8145	122	0	1	09	04	H8145_122_0	3	6		01	11a;				2			2		1	30	30
H8145	122	0	1	09	04	H8145_122_0	3	9		10		13b;	1	25.00	2			2		1	50	50
H8145	122	0	1	09	04	H8145_122_0	3	8		10		13c;14c;	2		2			2		1	50	50
H8145	122	0	1	09	04	H8145_122_0	3	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;17b;18a;	13d;14b;	2		2			2		1	40	40
H8145	123	0	1	09	04	H8145_123_0	3	8		01	7b;7c;7e;7h;7i;				1	40.00	40.00	2		2		
H8145	123	0	1	09	04	H8145_123_0	3	7		01	9c;				1	40.00	100.00	2		2		
H8145	123	0	1	09	04	H8145_123_0	3	6		01	10a;				1	300.00	300.00	2		2		
H8145	123	0	1	09	04	H8145_123_0	3	5		01	17b;				1	25.00	25.00	2		2		
H8145	123	0	1	09	04	H8145_123_0	3	4		01	7a;				1	15.00	15.00	2		2		
H8145	123	0	1	09	04	H8145_123_0	3	3		01	8b3;				1	15.00	100.00	2		2		
H8145	123	0	1	09	04	H8145_123_0	3	2		01	8a2;17a;				1	0.00	50.00	2		2		
H8145	123	0	1	09	04	H8145_123_0	3	15		10		13b;	1	10.00	2			2		1	50	50
H8145	123	0	1	09	04	H8145_123_0	3	14		10		13c;14c;16a;16b;	2		2			2		1	50	50
H8145	123	0	1	09	04	H8145_123_0	3	13		01	8b1;8b2;				1	50.00	275.00	2		1	25	25
H8145	123	0	1	09	04	H8145_123_0	3	12		01	8a1;				1	0.00	100.00	2		1	25	25
H8145	123	0	1	09	04	H8145_123_0	3	11		01	9a;9b;11a;11b;11c;15;				2			2		1	25	25
H8145	123	0	1	09	04	H8145_123_0	3	10		01	12;				2			2		1	20	20
H8145	123	0	1	09	04	H8145_123_0	3	1		11	6;9d;14a;14d;14e;	9d;13d;14b;17a;	2		1	0.00	0.00	2		2		
H8145	123	0	1	09	04	H8145_123_0	3	9		01	3-1;3-2;3-3;5;7d;7f;7g;16b;18a;				1	50.00	50.00	2		2		
H8145	125	0	1	09	04	H8145_125_0	3	6		01	14a;				1	0.00	0.00	2		1	30	30
H8145	125	0	1	09	04	H8145_125_0	3	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;17b;18a;	13d;14b;	2		2			2		1	30	30
H8145	125	0	1	09	04	H8145_125_0	3	4		01	11a;				2			2		1	25	25
H8145	125	0	1	09	04	H8145_125_0	3	3		01	12;				2			2		1	20	20
H8145	125	0	1	09	04	H8145_125_0	3	2		01	10a;				1	300.00	300.00	2		2		
H8145	125	0	1	09	04	H8145_125_0	3	1		11	9d;	9d;17a;	2		1	0.00	0.00	2		2		
H8145	125	0	1	09	04	H8145_125_0	3	7		10		13c;14c;	2		2			2		1	50	50
H8145	125	0	1	09	04	H8145_125_0	3	8		10		13b;	1	25.00	2			2		1	50	50
H8145	126	0	1	09	04	H8145_126_0	2	3		01	10a;				1	300.00	300.00	2		2		
H8145	126	0	1	09	04	H8145_126_0	2	2		01	7a;				1	20.00	20.00	2		2		
H8145	126	0	1	09	04	H8145_126_0	2	12		10		13b;	1	10.00	2			2		1	50	50
H8145	126	0	1	09	04	H8145_126_0	2	11		10		13c;14c;	2		2			2		1	50	50
H8145	126	0	1	09	04	H8145_126_0	2	10		01	3-1;3-2;3-3;7c;7i;8b1;9c;17a;				1	50.00	50.00	2		1	30	30
H8145	126	0	1	09	04	H8145_126_0	2	1		11	9d;	9d;17a;	2		1	0.00	0.00	2		2		
H8145	126	0	1	09	04	H8145_126_0	2	4		01	7b;7d;7e;7f;7g;7h;16b;18a;				1	50.00	50.00	2		2		
H8145	126	0	1	09	04	H8145_126_0	2	9		01	8a1;8a2;8b3;				1	20.00	50.00	2		1	30	30
H8145	126	0	1	09	04	H8145_126_0	2	8		11	5;6;8b2;9a;9b;14d;14e;17b;	13d;14b;	2		2			2		1	30	30
H8145	126	0	1	09	04	H8145_126_0	2	7		01	15;				2			2		1	20	30
H8145	126	0	1	09	04	H8145_126_0	2	6		01	11a;11b;11c;12;				2			2		1	20	20
H8145	126	0	1	09	04	H8145_126_0	2	5		01	14a;				2			2		1	0	30
H8145	155	0	1	09	04	H8145_155_0	2	1		11	9d;	9d;	2		1	0.00	0.00	2		2		
H8145	155	0	1	09	04	H8145_155_0	2	10		10		13b;	1	10.00	2			2		1	50	50
H8145	155	0	1	09	04	H8145_155_0	2	2		01	10a;				1	300.00	300.00	2		2		
H8145	155	0	1	09	04	H8145_155_0	2	3		01	14a;				2			2		1	0	30
H8145	155	0	1	09	04	H8145_155_0	2	9		10		13c;14c;	2		2			2		1	50	50
H8145	155	0	1	09	04	H8145_155_0	2	7		01	8a1;				2			2		1	25	30
H8145	155	0	1	09	04	H8145_155_0	2	6		01	6;				2			2		1	25	25
H8145	155	0	1	09	04	H8145_155_0	2	5		01	11c;				2			2		1	20	30
H8145	155	0	1	09	04	H8145_155_0	2	4		01	11a;12;15;				2			2		1	20	20
H8145	155	0	1	09	04	H8145_155_0	2	8		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;16b;17a;17b;18a;	13d;14b;	2		2			2		1	30	30
H8552	020	0	1	04	01	H8552_020_0	10	7	30% OON Group	01	11a;11b;11c;		2		2			2		1	30	30
H8552	020	0	1	04	01	H8552_020_0	10	6	$0 Copayment	01	16b;17a;17b;		2		1	0.00	0.00	2		2		
H8552	020	0	1	04	01	H8552_020_0	10	9	20% Coinsurance Group	11	12;15;	16a;	2		2			2		1	20	20
H8552	020	0	1	04	01	H8552_020_0	10	8	$0 Copayment Group	10		14c;	1	95.00	1	0.00	0.00	2		2		
H8552	020	0	1	04	01	H8552_020_0	10	5	50% OON Coinsurance Group	01	8a1;8a2;8b1;8b2;8b3;		2		2			2		1	50	50
H8552	020	0	1	04	01	H8552_020_0	10	4	20% Coinsurance Air $325 Copayment Group	01	10a;		2		1	325.00	325.00	2		1	20	20
H8552	020	0	1	04	01	H8552_020_0	10	3	$50 Copayment Group	01	7b;7c;7d;7e;7f;7h;7i;		2		1	50.00	50.00	2		2		
H8552	020	0	1	04	01	H8552_020_0	10	2	$30 OON Copayment Group	01	7a;7g;		2		1	30.00	30.00	2		2		
H8552	020	0	1	04	01	H8552_020_0	10	10	$0 Copay Group with $69 Max Benefit	10		17a;	2		1	0.00	0.00	2		2		
H8552	020	0	1	04	01	H8552_020_0	10	1	40% OON Coinsurance Group	11	3-1;3-2;3-3;5;6;9a;9b;9c;9d;14a;14d;14e;18a;	9d;14b;	2		2			2		1	40	40
H8552	021	0	1	04	01	H8552_021_0	10	7	50% OON Group	01	8a1;8a2;8b1;8b2;8b3;9a;9b;		2		2			2		1	50	50
H8552	021	0	1	04	01	H8552_021_0	10	1	40% OON Coinsurance Group	11	3-1;3-2;3-3;5;6;9c;9d;14a;14d;14e;15;18a;	9d;14b;	2		2			2		1	40	40
H8552	021	0	1	04	01	H8552_021_0	10	9	$0 Copayment Group	10		14c;	1	95.00	1	0.00	0.00	2		2		
H8552	021	0	1	04	01	H8552_021_0	10	8	$0 Copay Group with $69 Max Benefit	10		17a;	2		1	0.00	0.00	2		2		
H8552	021	0	1	04	01	H8552_021_0	10	10	35% Coinsurance Group	01	11a;11b;11c;		2		2			2		1	35	35
H8552	021	0	1	04	01	H8552_021_0	10	2	$35 OON Copayment Group	01	7a;7g;		2		1	35.00	35.00	2		2		
H8552	021	0	1	04	01	H8552_021_0	10	3	$50 Copayment Group	01	7b;7c;7d;7e;7f;7h;7i;		2		1	50.00	50.00	2		2		
H8552	021	0	1	04	01	H8552_021_0	10	4	20% Coinsurance Air $325 Copayment Group	01	10a;		2		1	325.00	325.00	2		1	20	20
H8552	021	0	1	04	01	H8552_021_0	10	5	20% OON Coinsurance Group	11	12;	16a;	2		2			2		1	20	20
H8552	021	0	1	04	01	H8552_021_0	10	6	$0 Copayment	01	16b;17a;17b;		2		1	0.00	0.00	2		2		
H8552	801	0	1	04	01	H8552_801_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H8552	801	0	1	04	01	H8552_801_0	4	1		01	6;14a;		2		2			2		1	0	0
H8552	802	0	1	04	01	H8552_802_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H8552	802	0	1	04	01	H8552_802_0	4	1		01	6;14a;		2		2			2		1	0	0
H8552	803	0	1	04	01	H8552_803_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H8552	803	0	1	04	01	H8552_803_0	4	1		01	6;14a;		2		2			2		1	0	0
H8604	010	0	1	04	01	H8604_010_0	11	7	Group 7	01	8a1;8a2;14e;		2		2			2		1	20	20
H8604	010	0	1	04	01	H8604_010_0	11	8	Group 8	01	17a;		2		1	20.00	45.00	2		2		
H8604	010	0	1	04	01	H8604_010_0	11	1	Group 1	11	3-1;3-2;3-3;5;6;8b1;8b2;8b3;9a;9b;9d;12;14a;14d;15;17b;	9d;14c;	2		2			2		1	20	20
H8604	010	0	1	04	01	H8604_010_0	11	2	Group 2	01	11a;11b;11c;		2		2			2		1	30	30
H8604	010	0	1	04	01	H8604_010_0	11	3	Group 3	01	7a;		2		1	20.00	20.00	2		2		
H8604	010	0	1	04	01	H8604_010_0	11	4	Group 4	11	7b;7c;7d;7e;7f;7g;7h;7i;9c;16b;18a;	7f;17a;	2		1	45.00	45.00	2		2		
H8604	010	0	1	04	01	H8604_010_0	11	5	Group 5	01	10a;		2		1	125.00	125.00	2		2		
H8604	010	0	1	04	01	H8604_010_0	11	6	Group 6	10		17b;	2		2			2		1	20	20
H8604	011	0	1	04	01	H8604_011_0	12	1	Group 1	11	3-1;3-2;3-3;5;6;8b1;8b2;8b3;9a;9b;9d;12;14a;14d;15;17b;	9d;14c;	2		2			2		1	20	20
H8604	011	0	1	04	01	H8604_011_0	12	2	Group 2	01	11a;11b;11c;		2		2			2		1	30	30
H8604	011	0	1	04	01	H8604_011_0	12	3	Group 3	01	7a;		2		1	20.00	20.00	2		2		
H8604	011	0	1	04	01	H8604_011_0	12	4	Group 4	11	7b;7c;7d;7e;7f;7g;7h;7i;9c;16b;18a;	7f;17a;	2		1	45.00	45.00	2		2		
H8604	011	0	1	04	01	H8604_011_0	12	5	Group 5	01	10a;		2		1	125.00	125.00	2		2		
H8604	011	0	1	04	01	H8604_011_0	12	6	Group 6	10		17b;	2		2			2		1	20	20
H8604	011	0	1	04	01	H8604_011_0	12	7	Group 7	01	8a1;8a2;14e;		2		2			2		1	20	20
H8604	011	0	1	04	01	H8604_011_0	12	8	Group 8	01	17a;		2		1	20.00	45.00	2		2		
H8604	013	0	1	04	01	H8604_013_0	10	1	Group 1	11	3-1;3-2;3-3;5;6;8b1;8b2;8b3;9a;9b;9d;12;14a;14d;15;17b;	9d;14c;	2		2			2		1	20	20
H8604	013	0	1	04	01	H8604_013_0	10	8	Group 8	01	17a;		2		1	20.00	45.00	2		2		
H8604	013	0	1	04	01	H8604_013_0	10	2	Group 2	01	11a;11b;11c;		2		2			2		1	30	30
H8604	013	0	1	04	01	H8604_013_0	10	3	Group 3	01	7a;		2		1	20.00	20.00	2		2		
H8604	013	0	1	04	01	H8604_013_0	10	4	Group 4	11	7b;7c;7d;7e;7f;7g;7h;7i;9c;16b;18a;	7f;17a;	2		1	45.00	45.00	2		2		
H8604	013	0	1	04	01	H8604_013_0	10	5	Group 5	01	10a;		2		1	125.00	125.00	2		2		
H8604	013	0	1	04	01	H8604_013_0	10	6	Group 6	10		17b;	2		2			2		1	20	20
H8604	013	0	1	04	01	H8604_013_0	10	7	Group 7	01	8a1;8a2;14e;		2		2			2		1	20	20
H8604	801	0	1	04	01	H8604_801_0	6	1		01	6;14a;		2		2			2		1	0	0
H8604	801	0	1	04	01	H8604_801_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H8634	001	0	1	04	01	H8634_001_0	8	8	Hearing Aids	10		18b;	2		2			2		2		
H8634	001	0	1	04	01	H8634_001_0	8	7	Preventive Dental	10		16a;	2		1	5.00	5.00	2		2		
H8634	001	0	1	04	01	H8634_001_0	8	6	Vision Eyewear - Frames	10		17b;	2		2			2		2		
H8634	001	0	1	04	01	H8634_001_0	8	5	Vision Eye Exam	10		17a;	2		2			2		2		
H8634	001	0	1	04	01	H8634_001_0	8	4	0 Copay/0 Coinsurance	11	9d;14e;	14c;	2		2			2		2		
H8634	001	0	1	04	01	H8634_001_0	8	3	20% Coinsurance	01	12;15;		2		2			2		1	20	20
H8634	001	0	1	04	01	H8634_001_0	8	2	$200 Copay	01	10a;		2		1	200.00	200.00	2		2		
H8634	001	0	1	04	01	H8634_001_0	8	1	30% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14a;14d;16b;17a;17b;18a;	14b;18a;	2		2			2		1	30	30
H8634	002	0	1	04	01	H8634_002_0	9	1	40% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14a;14d;15;16b;17a;17b;18a;	14b;	2		2			2		1	40	40
H8634	002	0	1	04	01	H8634_002_0	9	5	Preventive Dental	10		16a;	2		1	5.00	5.00	2		2		
H8634	002	0	1	04	01	H8634_002_0	9	4	$ 0 copay	11	14e;	14c;	2		2			2		2		
H8634	002	0	1	04	01	H8634_002_0	9	3	20% Coinsurance	01	12;		2		2			2		1	20	20
H8634	002	0	1	04	01	H8634_002_0	9	2	$200 Copay	01	10a;		2		1	200.00	200.00	2		2		
H8634	003	0	1	04	01	H8634_003_0	10	2	$200	01	10a;		2		1	200.00	200.00	2		2		
H8634	003	0	1	04	01	H8634_003_0	10	1	40%	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14a;14d;15;16b;17a;17b;18a;	14b;	2		2			2		1	40	40
H8634	003	0	1	04	01	H8634_003_0	10	3	20%	01	12;		2		2			2		1	20	20
H8634	003	0	1	04	01	H8634_003_0	10	4	$0	11	9d;14e;	10b;14c;	2		1	0.00	0.00	2		2		
H8634	004	0	1	04	01	H8634_004_0	11	8	OTC Allowance	10		13b;	1	30.00	2			2		2		
H8634	004	0	1	04	01	H8634_004_0	11	7	$1000 Hearing Aids Allowance	10		18b;	2		2			2		2		
H8634	004	0	1	04	01	H8634_004_0	11	6	$100 Vision Eyewear-Frames Allowance	10		17b;	2		2			2		2		
H8634	004	0	1	04	01	H8634_004_0	11	5	$40  Eye Exam Allowance	10		17a;	2		2			2		2		
H8634	004	0	1	04	01	H8634_004_0	11	4	$0 Copay	11	14e;	10b;14c;16a;	2		2			2		2		
H8634	004	0	1	04	01	H8634_004_0	11	3	20%	01	12;15;		2		2			2		1	20	20
H8634	004	0	1	04	01	H8634_004_0	11	2	$200	01	10a;		2		1	200.00	200.00	2		2		
H8634	004	0	1	04	01	H8634_004_0	11	1	30% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14a;14d;16b;17a;17b;18a;	14b;18a;	2		2			2		1	30	30
H8634	004	0	1	04	01	H8634_004_0	11	9	$1000 Allowance	10		16b;	2		2			2		2		
H8634	006	0	1	04	01	H8634_006_0	10	1	30% Coinsurance	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14a;14d;16b;17a;17b;18a;	14b;18a;	2		2			2		1	30	30
H8634	006	0	1	04	01	H8634_006_0	10	2	$200 Copay	01	10a;		2		1	200.00	200.00	2		2		
H8634	006	0	1	04	01	H8634_006_0	10	3	20% Coinsurance	01	12;15;		2		2			2		1	20	20
H8634	006	0	1	04	01	H8634_006_0	10	4	0 Copay/0 Coinsurance	11	9d;14e;	14c;	2		2			2		2		
H8634	006	0	1	04	01	H8634_006_0	10	5	Vision Eye Exam	10		17a;	2		2			2		2		
H8634	006	0	1	04	01	H8634_006_0	10	6	Vision Eyewear - Frames	10		17b;	2		2			2		2		
H8634	006	0	1	04	01	H8634_006_0	10	8	Hearing Aids	10		18b;	2		2			2		2		
H8634	006	0	1	04	01	H8634_006_0	10	7	Preventive Dental	10		16a;	2		1	5.00	5.00	2		2		
H8634	801	0	1	04	01	H8634_801_0	3	1		01	6;14a;		2		2			2		1	0	0
H8634	801	0	1	04	01	H8634_801_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H8634	803	0	1	04	01	H8634_803_0	3	1		01	6;14a;		2		2			2		1	0	0
H8634	803	0	1	04	01	H8634_803_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H8634	805	0	1	04	01	H8634_805_0	3	1		01	6;14a;		2		2			2		1	0	0
H8634	805	0	1	04	01	H8634_805_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H8634	807	0	1	04	01	H8634_807_0	3	1		01	6;14a;		2		2			2		1	0	0
H8634	807	0	1	04	01	H8634_807_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H8634	809	0	1	04	01	H8634_809_0	3	1		01	6;14a;		2		2			2		1	0	0
H8634	809	0	1	04	01	H8634_809_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H8634	811	0	1	04	01	H8634_811_0	3	1		01	6;14a;		2		2			2		1	0	0
H8634	811	0	1	04	01	H8634_811_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H8634	813	0	1	04	01	H8634_813_0	5	1		01	6;14a;		2		2			2		1	0	0
H8634	813	0	1	04	01	H8634_813_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H8634	815	0	1	04	01	H8634_815_0	5	1		01	6;14a;		2		2			2		1	0	0
H8634	815	0	1	04	01	H8634_815_0	5	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H8634	817	0	1	04	01	H8634_817_0	7	1		01	6;14a;		2		2			2		1	0	0
H8634	817	0	1	04	01	H8634_817_0	7	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H9312	001	0	1	04	01	H9312_001_0	6	1	Outpatient	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	14c;	2		2			2		1	30	30
H9312	001	0	1	04	01	H9312_001_0	6	2	Transportation	10		10b;	2		2			2		1	50	50
H9312	001	0	1	04	01	H9312_001_0	6	3	Dental	10		16a;16b;	2		2			2		1	50	50
H9312	001	0	1	04	01	H9312_001_0	6	4	OTC	10		13b;	1	20.00	2			2		2		
H9312	001	0	1	04	01	H9312_001_0	6	5	Eyewear	10		17b;	2		2			2		1	50	50
H9312	001	0	1	04	01	H9312_001_0	6	6	Eye exams	10		17a;	2		2			2		1	50	50
H9312	002	0	1	04	01	H9312_002_0	5	1	Outpatient	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14a;14d;14e;15;16b;17a;17b;18a;	14c;	2		2			2		1	30	30
H9312	002	0	1	04	01	H9312_002_0	5	2	Transportation	10		10b;	2		2			2		1	50	50
H9312	002	0	1	04	01	H9312_002_0	5	3	Dental	10		16a;16b;	2		2			2		1	50	50
H9312	002	0	1	04	01	H9312_002_0	5	4	OTC	10		13b;	1	20.00	2			2		2		
H9312	002	0	1	04	01	H9312_002_0	5	5	Eyewear	10		17b;	2		2			2		1	50	50
H9312	002	0	1	04	01	H9312_002_0	5	6	Eye exams	10		17a;	2		2			2		1	50	50
H9412	003	0	1	04	01	H9412_003_0	8	3	30% Coinsurance Benefit	01	8b2;		2		2			2		1	30	30
H9412	003	0	1	04	01	H9412_003_0	8	4	$30 Copayment Benefits	11	7d;7f;7g;14a;14d;14e;16b;17a;18a;	7f;17a;18a;	2		1	30.00	30.00	2		2		
H9412	003	0	1	04	01	H9412_003_0	8	5	$15 Copayment Benefits	11	7a;	14b;	2		1	15.00	15.00	2		2		
H9412	003	0	1	04	01	H9412_003_0	8	6	Ambulance	01	10a;		2		1	200.00	200.00	2		2		
H9412	003	0	1	04	01	H9412_003_0	8	7	Routine Eyewear	10		17b;	2		1	0.00	0.00	2		2		
H9412	003	0	1	04	01	H9412_003_0	8	2	25% Coinsurance Benefits	01	12;15;		2		2			2		1	25	25
H9412	003	0	1	04	01	H9412_003_0	8	9	Diagnostic Radiology Services	01	8b1;		2		2			2		1	20	35
H9412	003	0	1	04	01	H9412_003_0	8	1	20% Coinsurance Benefits	11	3-1;3-2;3-3;5;6;7b;7c;7e;7h;7i;8a1;8a2;8b3;9a;9b;9c;9d;11a;11b;17b;	16a;	2		2			2		1	20	20
H9412	003	0	1	04	01	H9412_003_0	8	10	Diabetic Supplies	01	11c;		2		2			2		1	0	25
H9412	003	0	1	04	01	H9412_003_0	8	11	Eligible Supplemental Benefits	10		14c;	1	90.00	2			2		2		
H9412	003	0	1	04	01	H9412_003_0	8	8	Hearing Aid and Hearing Aid Fitting	10		18b;	2		1	0.00	0.00	2		2		
H9572	001	1	1	04	01	H9572_001_1	7	1	Global coinsurance group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;15;16b;17a;17b;	7b;	2		2			2		1	40	40
H9572	001	1	1	04	01	H9572_001_1	7	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2		2		
H9572	001	1	1	04	01	H9572_001_1	7	3	Hearing exams	11	18a;	18a;	2		2			2		1	50	50
H9572	001	1	1	04	01	H9572_001_1	7	4	Preventive Dental	10		16a;	2		2			2		1	50	50
H9572	001	1	1	04	01	H9572_001_1	7	8	Supplemental Vision - Eyewear	10		17b;	2		2			2		2		
H9572	001	1	1	04	01	H9572_001_1	7	6	Supplemental Vision	10		17a;	2		1	0.00	10.00	2		1	40	40
H9572	001	1	1	04	01	H9572_001_1	7	7	Hearing Aids	10		18b;	2		2			2		2		
H9572	001	1	1	04	01	H9572_001_1	7	9	Ambulance Services	01	10a;		2		1	125.00	125.00	2		1	40	40
H9572	001	1	1	04	01	H9572_001_1	7	5	Zero Coinsurance/copay group	11	9d;11c;14a;14e;	9d;13e;14b;	2		2			2		2		
H9572	001	2	1	04	01	H9572_001_2	7	3	Hearing exams	11	18a;	18a;	2		2			2		1	50	50
H9572	001	2	1	04	01	H9572_001_2	7	4	Preventive Dental	10		16a;	2		2			2		1	50	50
H9572	001	2	1	04	01	H9572_001_2	7	5	Zero Coinsurance/copay group	11	9d;11c;14a;14e;	9d;13e;14b;	2		2			2		2		
H9572	001	2	1	04	01	H9572_001_2	7	6	Supplemental Vision	10		17a;	2		1	0.00	10.00	2		1	40	40
H9572	001	2	1	04	01	H9572_001_2	7	7	Hearing Aids	10		18b;	2		2			2		2		
H9572	001	2	1	04	01	H9572_001_2	7	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2		2		
H9572	001	2	1	04	01	H9572_001_2	7	9	Ambulance Services	01	10a;		2		1	125.00	125.00	2		1	40	40
H9572	001	2	1	04	01	H9572_001_2	7	8	Supplemental Vision - Eyewear	10		17b;	2		2			2		2		
H9572	001	2	1	04	01	H9572_001_2	7	1	Global coinsurance group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;15;16b;17a;17b;	7b;	2		2			2		1	40	40
H9572	001	3	1	04	01	H9572_001_3	7	5	Zero Coinsurance/copay group	11	9d;11c;14a;14e;	9d;13e;14b;	2		2			2		2		
H9572	001	3	1	04	01	H9572_001_3	7	6	Supplemental Vision	10		17a;	2		1	0.00	10.00	2		1	40	40
H9572	001	3	1	04	01	H9572_001_3	7	7	Hearing Aids	10		18b;	2		2			2		2		
H9572	001	3	1	04	01	H9572_001_3	7	8	Supplemental Vision - Eyewear	10		17b;	2		2			2		2		
H9572	001	3	1	04	01	H9572_001_3	7	3	Hearing exams	11	18a;	18a;	2		2			2		1	50	50
H9572	001	3	1	04	01	H9572_001_3	7	1	Global coinsurance group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;15;16b;17a;17b;	7b;	2		2			2		1	40	40
H9572	001	3	1	04	01	H9572_001_3	7	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2		2		
H9572	001	3	1	04	01	H9572_001_3	7	4	Preventive Dental	10		16a;	2		2			2		1	50	50
H9572	001	3	1	04	01	H9572_001_3	7	9	Ambulance Services	01	10a;		2		1	125.00	125.00	2		1	40	40
H9572	001	4	1	04	01	H9572_001_4	7	9	Ambulance Services	01	10a;		2		1	125.00	125.00	2		1	40	40
H9572	001	4	1	04	01	H9572_001_4	7	8	Supplemental Vision - Eyewear	10		17b;	2		2			2		2		
H9572	001	4	1	04	01	H9572_001_4	7	7	Hearing Aids	10		18b;	2		2			2		2		
H9572	001	4	1	04	01	H9572_001_4	7	6	Supplemental Vision	10		17a;	2		1	0.00	10.00	2		1	40	40
H9572	001	4	1	04	01	H9572_001_4	7	5	Zero Coinsurance/copay group	11	9d;11c;14a;14e;	9d;13e;14b;	2		2			2		2		
H9572	001	4	1	04	01	H9572_001_4	7	4	Preventive Dental	10		16a;	2		2			2		1	50	50
H9572	001	4	1	04	01	H9572_001_4	7	3	Hearing exams	11	18a;	18a;	2		2			2		1	50	50
H9572	001	4	1	04	01	H9572_001_4	7	1	Global coinsurance group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;15;16b;17a;17b;	7b;	2		2			2		1	40	40
H9572	001	4	1	04	01	H9572_001_4	7	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2		2		
H9572	001	6	1	04	01	H9572_001_6	6	7	Hearing Aids	10		18b;	2		2			2		2		
H9572	001	6	1	04	01	H9572_001_6	6	6	Supplemental Vision	10		17a;	2		1	0.00	10.00	2		1	40	40
H9572	001	6	1	04	01	H9572_001_6	6	5	Zero Coinsurance/copay group	11	9d;11c;14a;14e;	9d;13e;14b;	2		2			2		2		
H9572	001	6	1	04	01	H9572_001_6	6	4	Preventive Dental	10		16a;	2		2			2		1	50	50
H9572	001	6	1	04	01	H9572_001_6	6	9	Ambulance Services	01	10a;		2		1	125.00	125.00	2		1	40	40
H9572	001	6	1	04	01	H9572_001_6	6	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2		2		
H9572	001	6	1	04	01	H9572_001_6	6	1	Global coinsurance group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;15;16b;17a;17b;	7b;	2		2			2		1	40	40
H9572	001	6	1	04	01	H9572_001_6	6	8	Supplemental Vision - Eyewear	10		17b;	2		2			2		2		
H9572	001	6	1	04	01	H9572_001_6	6	3	Hearing exams	11	18a;	18a;	2		2			2		1	50	50
H9572	002	1	1	04	01	H9572_002_1	7	4	Preventive Dental	10		16a;	2		2			2		1	50	50
H9572	002	1	1	04	01	H9572_002_1	7	3	Hearing exams	11	18a;	18a;	2		2			2		1	50	50
H9572	002	1	1	04	01	H9572_002_1	7	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2		2		
H9572	002	1	1	04	01	H9572_002_1	7	1	Global coinsurance group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;15;16b;17a;17b;	7b;	2		2			2		1	40	40
H9572	002	1	1	04	01	H9572_002_1	7	9	Ambulance Services	01	10a;		2		1	150.00	150.00	2		1	40	40
H9572	002	1	1	04	01	H9572_002_1	7	6	Supplemental Vision	10		17a;	2		1	0.00	10.00	2		1	40	40
H9572	002	1	1	04	01	H9572_002_1	7	7	Hearing aids	10		18b;	2		2			2		2		
H9572	002	1	1	04	01	H9572_002_1	7	8	Supplemental Vision - Eyewear	10		17b;	2		2			2		2		
H9572	002	1	1	04	01	H9572_002_1	7	5	Zero coinsurance/copay group	11	9d;11c;14a;14e;	9d;13e;14b;	2		2			2		2		
H9572	002	2	1	04	01	H9572_002_2	7	4	Preventive Dental	10		16a;	2		2			2		1	50	50
H9572	002	2	1	04	01	H9572_002_2	7	3	Hearing exams	11	18a;	18a;	2		2			2		1	50	50
H9572	002	2	1	04	01	H9572_002_2	7	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2		2		
H9572	002	2	1	04	01	H9572_002_2	7	1	Global coinsurance group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;15;16b;17a;17b;	7b;	2		2			2		1	40	40
H9572	002	2	1	04	01	H9572_002_2	7	5	Zero coinsurance/copay group	11	9d;11c;14a;14e;	9d;13e;14b;	2		2			2		2		
H9572	002	2	1	04	01	H9572_002_2	7	9	Ambulance Services	01	10a;		2		1	150.00	150.00	2		1	40	40
H9572	002	2	1	04	01	H9572_002_2	7	8	Supplemental Vision - Eyewear	10		17b;	2		2			2		2		
H9572	002	2	1	04	01	H9572_002_2	7	7	Hearing aids	10		18b;	2		2			2		2		
H9572	002	2	1	04	01	H9572_002_2	7	6	Supplemental Vision	10		17a;	2		1	0.00	10.00	2		1	40	40
H9572	002	3	1	04	01	H9572_002_3	7	1	Global coinsurance group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;15;16b;17a;17b;	7b;	2		2			2		1	40	40
H9572	002	3	1	04	01	H9572_002_3	7	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2		2		
H9572	002	3	1	04	01	H9572_002_3	7	3	Hearing exams	11	18a;	18a;	2		2			2		1	50	50
H9572	002	3	1	04	01	H9572_002_3	7	4	Preventive Dental	10		16a;	2		2			2		1	50	50
H9572	002	3	1	04	01	H9572_002_3	7	9	Ambulance Services	01	10a;		2		1	150.00	150.00	2		1	40	40
H9572	002	3	1	04	01	H9572_002_3	7	7	Hearing aids	10		18b;	2		2			2		2		
H9572	002	3	1	04	01	H9572_002_3	7	6	Supplemental Vision	10		17a;	2		1	0.00	10.00	2		1	40	40
H9572	002	3	1	04	01	H9572_002_3	7	5	Zero coinsurance/copay group	11	9d;11c;14a;14e;	9d;13e;14b;	2		2			2		2		
H9572	002	3	1	04	01	H9572_002_3	7	8	Supplemental Vision - Eyewear	10		17b;	2		2			2		2		
H9572	002	4	1	04	01	H9572_002_4	7	9	Ambulance Services	01	10a;		2		1	150.00	150.00	2		1	40	40
H9572	002	4	1	04	01	H9572_002_4	7	1	Global coinsurance group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;15;16b;17a;17b;	7b;	2		2			2		1	40	40
H9572	002	4	1	04	01	H9572_002_4	7	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2		2		
H9572	002	4	1	04	01	H9572_002_4	7	3	Hearing exams	11	18a;	18a;	2		2			2		1	50	50
H9572	002	4	1	04	01	H9572_002_4	7	4	Preventive Dental	10		16a;	2		2			2		1	50	50
H9572	002	4	1	04	01	H9572_002_4	7	5	Zero coinsurance/copay group	11	9d;11c;14a;14e;	9d;13e;14b;	2		2			2		2		
H9572	002	4	1	04	01	H9572_002_4	7	6	Supplemental Vision	10		17a;	2		1	0.00	10.00	2		1	40	40
H9572	002	4	1	04	01	H9572_002_4	7	7	Hearing aids	10		18b;	2		2			2		2		
H9572	002	4	1	04	01	H9572_002_4	7	8	Supplemental Vision - Eyewear	10		17b;	2		2			2		2		
H9572	002	6	1	04	01	H9572_002_6	7	1	Global coinsurance group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;15;16b;17a;17b;	7b;	2		2			2		1	40	40
H9572	002	6	1	04	01	H9572_002_6	7	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2		2		
H9572	002	6	1	04	01	H9572_002_6	7	3	Hearing exams	11	18a;	18a;	2		2			2		1	50	50
H9572	002	6	1	04	01	H9572_002_6	7	4	Preventive Dental	10		16a;	2		2			2		1	50	50
H9572	002	6	1	04	01	H9572_002_6	7	9	Ambulance Services	01	10a;		2		1	150.00	150.00	2		1	40	40
H9572	002	6	1	04	01	H9572_002_6	7	6	Supplemental Vision	10		17a;	2		1	0.00	10.00	2		1	40	40
H9572	002	6	1	04	01	H9572_002_6	7	7	Hearing aids	10		18b;	2		2			2		2		
H9572	002	6	1	04	01	H9572_002_6	7	8	Supplemental Vision - Eyewear	10		17b;	2		2			2		2		
H9572	002	6	1	04	01	H9572_002_6	7	5	Zero coinsurance/copay group	11	9d;11c;14a;14e;	9d;13e;14b;	2		2			2		2		
H9572	003	1	1	04	01	H9572_003_1	7	7	Hearing aids	10		18b;	2		2			2		2		
H9572	003	1	1	04	01	H9572_003_1	7	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2		2		
H9572	003	1	1	04	01	H9572_003_1	7	5	Zero coinsurance/copay group	11	9d;11c;14a;14e;	9d;13e;14b;	2		2			2		2		
H9572	003	1	1	04	01	H9572_003_1	7	3	Hearing exams	11	18a;	18a;	2		2			2		1	50	50
H9572	003	1	1	04	01	H9572_003_1	7	8	Supplemental Vision - Eyewear	10		17b;	2		2			2		2		
H9572	003	1	1	04	01	H9572_003_1	7	9	Ambulance Services	01	10a;		2		1	125.00	125.00	2		1	30	30
H9572	003	1	1	04	01	H9572_003_1	7	6	Supplemental Vision	10		17a;	2		1	0.00	10.00	2		1	30	30
H9572	003	1	1	04	01	H9572_003_1	7	1	Global coinsurance group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;15;16b;17a;17b;	7b;	2		2			2		1	30	30
H9572	003	1	1	04	01	H9572_003_1	7	4	Preventive Dental	10		16a;	2		2			2		1	50	50
H9572	003	2	1	04	01	H9572_003_2	7	4	Preventive Dental	10		16a;	2		2			2		1	50	50
H9572	003	2	1	04	01	H9572_003_2	7	5	Zero coinsurance/copay group	11	9d;11c;14a;14e;	9d;13e;14b;	2		2			2		2		
H9572	003	2	1	04	01	H9572_003_2	7	6	Supplemental Vision	10		17a;	2		1	0.00	10.00	2		1	30	30
H9572	003	2	1	04	01	H9572_003_2	7	7	Hearing aids	10		18b;	2		2			2		2		
H9572	003	2	1	04	01	H9572_003_2	7	1	Global coinsurance group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;15;16b;17a;17b;	7b;	2		2			2		1	30	30
H9572	003	2	1	04	01	H9572_003_2	7	9	Ambulance Services	01	10a;		2		1	125.00	125.00	2		1	30	30
H9572	003	2	1	04	01	H9572_003_2	7	3	Hearing exams	11	18a;	18a;	2		2			2		1	50	50
H9572	003	2	1	04	01	H9572_003_2	7	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2		2		
H9572	003	2	1	04	01	H9572_003_2	7	8	Supplemental Vision - Eyewear	10		17b;	2		2			2		2		
H9572	003	3	1	04	01	H9572_003_3	7	4	Preventive Dental	10		16a;	2		2			2		1	50	50
H9572	003	3	1	04	01	H9572_003_3	7	3	Hearing exams	11	18a;	18a;	2		2			2		1	50	50
H9572	003	3	1	04	01	H9572_003_3	7	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2		2		
H9572	003	3	1	04	01	H9572_003_3	7	1	Global coinsurance group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;15;16b;17a;17b;	7b;	2		2			2		1	30	30
H9572	003	3	1	04	01	H9572_003_3	7	5	Zero coinsurance/copay group	11	9d;11c;14a;14e;	9d;13e;14b;	2		2			2		2		
H9572	003	3	1	04	01	H9572_003_3	7	9	Ambulance Services	01	10a;		2		1	125.00	125.00	2		1	30	30
H9572	003	3	1	04	01	H9572_003_3	7	8	Supplemental Vision - Eyewear	10		17b;	2		2			2		2		
H9572	003	3	1	04	01	H9572_003_3	7	7	Hearing aids	10		18b;	2		2			2		2		
H9572	003	3	1	04	01	H9572_003_3	7	6	Supplemental Vision	10		17a;	2		1	0.00	10.00	2		1	30	30
H9572	003	4	1	04	01	H9572_003_4	7	1	Global coinsurance group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;15;16b;17a;17b;	7b;	2		2			2		1	30	30
H9572	003	4	1	04	01	H9572_003_4	7	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2		2		
H9572	003	4	1	04	01	H9572_003_4	7	9	Ambulance Services	01	10a;		2		1	125.00	125.00	2		1	30	30
H9572	003	4	1	04	01	H9572_003_4	7	8	Supplemental Vision - Eyewear	10		17b;	2		2			2		2		
H9572	003	4	1	04	01	H9572_003_4	7	7	Hearing aids	10		18b;	2		2			2		2		
H9572	003	4	1	04	01	H9572_003_4	7	6	Supplemental Vision	10		17a;	2		1	0.00	10.00	2		1	30	30
H9572	003	4	1	04	01	H9572_003_4	7	5	Zero coinsurance/copay group	11	9d;11c;14a;14e;	9d;13e;14b;	2		2			2		2		
H9572	003	4	1	04	01	H9572_003_4	7	4	Preventive Dental	10		16a;	2		2			2		1	50	50
H9572	003	4	1	04	01	H9572_003_4	7	3	Hearing exams	11	18a;	18a;	2		2			2		1	50	50
H9572	003	6	1	04	01	H9572_003_6	7	1	Global coinsurance group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;15;16b;17a;17b;	7b;	2		2			2		1	30	30
H9572	003	6	1	04	01	H9572_003_6	7	5	Zero coinsurance/copay group	11	9d;11c;14a;14e;	9d;13e;14b;	2		2			2		2		
H9572	003	6	1	04	01	H9572_003_6	7	6	Supplemental Vision	10		17a;	2		1	0.00	10.00	2		1	30	30
H9572	003	6	1	04	01	H9572_003_6	7	7	Hearing aids	10		18b;	2		2			2		2		
H9572	003	6	1	04	01	H9572_003_6	7	9	Ambulance Services	01	10a;		2		1	125.00	125.00	2		1	30	30
H9572	003	6	1	04	01	H9572_003_6	7	4	Preventive Dental	10		16a;	2		2			2		1	50	50
H9572	003	6	1	04	01	H9572_003_6	7	3	Hearing exams	11	18a;	18a;	2		2			2		1	50	50
H9572	003	6	1	04	01	H9572_003_6	7	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2		2		
H9572	003	6	1	04	01	H9572_003_6	7	8	Supplemental Vision - Eyewear	10		17b;	2		2			2		2		
H9572	004	1	1	04	01	H9572_004_1	7	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2		2		
H9572	004	1	1	04	01	H9572_004_1	7	1	Global coinsurance group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;15;16b;17a;17b;	7b;	2		2			2		1	40	40
H9572	004	1	1	04	01	H9572_004_1	7	3	Hearing exams	01	18a;		2		2			2		1	50	50
H9572	004	1	1	04	01	H9572_004_1	7	4	Zero coinsurance/copay group	11	9d;11c;14a;14e;	9d;13e;14b;	2		2			2		2		
H9572	004	1	1	04	01	H9572_004_1	7	5	Supplemental Vision	10		17a;	2		2			2		1	40	40
H9572	004	1	1	04	01	H9572_004_1	7	6	Ambulance Services	01	10a;		2		1	150.00	150.00	2		1	40	40
H9572	004	2	1	04	01	H9572_004_2	7	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2		2		
H9572	004	2	1	04	01	H9572_004_2	7	1	Global coinsurance group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;15;16b;17a;17b;	7b;	2		2			2		1	40	40
H9572	004	2	1	04	01	H9572_004_2	7	3	Hearing exams	01	18a;		2		2			2		1	50	50
H9572	004	2	1	04	01	H9572_004_2	7	6	Ambulance Services	01	10a;		2		1	150.00	150.00	2		1	40	40
H9572	004	2	1	04	01	H9572_004_2	7	5	Supplemental Vision	10		17a;	2		2			2		1	40	40
H9572	004	2	1	04	01	H9572_004_2	7	4	Zero coinsurance/copay group	11	9d;11c;14a;14e;	9d;13e;14b;	2		2			2		2		
H9572	004	3	1	04	01	H9572_004_3	7	1	Global coinsurance group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;15;16b;17a;17b;	7b;	2		2			2		1	40	40
H9572	004	3	1	04	01	H9572_004_3	7	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2		2		
H9572	004	3	1	04	01	H9572_004_3	7	5	Supplemental Vision	10		17a;	2		2			2		1	40	40
H9572	004	3	1	04	01	H9572_004_3	7	4	Zero coinsurance/copay group	11	9d;11c;14a;14e;	9d;13e;14b;	2		2			2		2		
H9572	004	3	1	04	01	H9572_004_3	7	3	Hearing exams	01	18a;		2		2			2		1	50	50
H9572	004	3	1	04	01	H9572_004_3	7	6	Ambulance Services	01	10a;		2		1	150.00	150.00	2		1	40	40
H9572	004	4	1	04	01	H9572_004_4	7	1	Global coinsurance group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;15;16b;17a;17b;	7b;	2		2			2		1	40	40
H9572	004	4	1	04	01	H9572_004_4	7	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2		2		
H9572	004	4	1	04	01	H9572_004_4	7	3	Hearing exams	01	18a;		2		2			2		1	50	50
H9572	004	4	1	04	01	H9572_004_4	7	4	Zero coinsurance/copay group	11	9d;11c;14a;14e;	9d;13e;14b;	2		2			2		2		
H9572	004	4	1	04	01	H9572_004_4	7	5	Supplemental Vision	10		17a;	2		2			2		1	40	40
H9572	004	4	1	04	01	H9572_004_4	7	6	Ambulance Services	01	10a;		2		1	150.00	150.00	2		1	40	40
H9572	004	6	1	04	01	H9572_004_6	7	4	Zero coinsurance/copay group	11	9d;11c;14a;14e;	9d;13e;14b;	2		2			2		2		
H9572	004	6	1	04	01	H9572_004_6	7	6	Ambulance Services	01	10a;		2		1	150.00	150.00	2		1	40	40
H9572	004	6	1	04	01	H9572_004_6	7	5	Supplemental Vision	10		17a;	2		2			2		1	40	40
H9572	004	6	1	04	01	H9572_004_6	7	3	Hearing exams	01	18a;		2		2			2		1	50	50
H9572	004	6	1	04	01	H9572_004_6	7	2	Eligible Supplemental Benefits	10		14c;	1	100.00	2			2		2		
H9572	004	6	1	04	01	H9572_004_6	7	1	Global coinsurance group	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;12;14d;15;16b;17a;17b;	7b;	2		2			2		1	40	40
H9572	801	0	1	04	01	H9572_801_0	3	1		01	6;14a;		2		2			2		1	0	0
H9572	801	0	1	04	01	H9572_801_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H9572	802	0	1	04	01	H9572_802_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H9572	802	0	1	04	01	H9572_802_0	3	1		01	6;14a;		2		2			2		1	0	0
H9572	803	0	1	04	01	H9572_803_0	4	1		01	6;14a;		2		2			2		1	0	0
H9572	803	0	1	04	01	H9572_803_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H9572	804	0	1	04	01	H9572_804_0	4	1		01	6;14a;		2		2			2		1	0	0
H9572	804	0	1	04	01	H9572_804_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H9572	805	0	1	04	01	H9572_805_0	4	1		01	6;14a;		2		2			2		1	0	0
H9572	805	0	1	04	01	H9572_805_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H9615	007	0	1	04	01	H9615_007_0	9	3	$20	01	7b;		2		1	20.00	20.00	2		2		
H9615	007	0	1	04	01	H9615_007_0	9	2	$60 Copay	11	3-1;3-2;3-3;5;7a;7c;7d;7e;7f;7g;7h;7i;8b3;9c;16b;17a;18a;	17a;18a;	2		1	60.00	60.00	2		2		
H9615	007	0	1	04	01	H9615_007_0	9	8	HealthDollars	10		14c;	1	100.00	2			2		2		
H9615	007	0	1	04	01	H9615_007_0	9	7	Hearing Aids	10		18b;	2		1	999.00	1399.00	2		2		
H9615	007	0	1	04	01	H9615_007_0	9	6	50% Coinsurance	10		13a;	2		2			2		1	50	50
H9615	007	0	1	04	01	H9615_007_0	9	5	$125 Copay	01	10a;		2		1	125.00	125.00	2		2		
H9615	007	0	1	04	01	H9615_007_0	9	4	$0	11	9d;12;14a;14d;14e;	9d;	2		1	0.00	0.00	2		2		
H9615	007	0	1	04	01	H9615_007_0	9	1	40%	01	6;8a1;8a2;8b1;8b2;9a;9b;11a;11b;11c;15;17b;		2		2			2		1	40	40
H9615	008	0	1	04	01	H9615_008_0	13	6	Hearing Aids	10		18b;	2		1	999.00	1399.00	2		2		
H9615	008	0	1	04	01	H9615_008_0	13	5	$200 Copay	01	10a;		2		1	200.00	200.00	2		2		
H9615	008	0	1	04	01	H9615_008_0	13	4	$0	11	9d;12;14a;14d;14e;	9d;	2		1	0.00	0.00	2		2		
H9615	008	0	1	04	01	H9615_008_0	13	3	$20	01	7b;		2		1	20.00	20.00	2		2		
H9615	008	0	1	04	01	H9615_008_0	13	2	$60 Copay	11	3-1;3-2;3-3;5;7a;7c;7d;7e;7f;7g;7h;7i;8b3;9c;16b;17a;18a;	17a;18a;	2		1	60.00	60.00	2		2		
H9615	008	0	1	04	01	H9615_008_0	13	1	40%	01	6;8a1;8a2;8b1;8b2;9a;9b;11a;11b;11c;15;17b;		2		2			2		1	40	40
H9615	008	0	1	04	01	H9615_008_0	13	7	HealthDollars	10		14c;	1	100.00	2			2		2		
H9615	009	0	1	04	01	H9615_009_0	10	3	$20	01	7b;		2		1	20.00	20.00	2		2		
H9615	009	0	1	04	01	H9615_009_0	10	2	$60 Copay	11	3-1;3-2;3-3;5;7a;7c;7d;7e;7f;7g;7h;7i;8b3;9c;16b;17a;18a;	17a;18a;	2		1	60.00	60.00	2		2		
H9615	009	0	1	04	01	H9615_009_0	10	1	40%	01	6;8a1;8a2;8b1;8b2;9a;9b;11a;11b;11c;15;17b;		2		2			2		1	40	40
H9615	009	0	1	04	01	H9615_009_0	10	4	$0	11	9d;12;14a;14d;14e;	9d;	2		1	0.00	0.00	2		2		
H9615	009	0	1	04	01	H9615_009_0	10	8	HealthDollars	10		14c;	1	100.00	2			2		2		
H9615	009	0	1	04	01	H9615_009_0	10	7	Hearing Aids	10		18b;	2		1	999.00	1399.00	2		2		
H9615	009	0	1	04	01	H9615_009_0	10	6	50% Coinsurance	10		13a;	2		2			2		1	50	50
H9615	009	0	1	04	01	H9615_009_0	10	5	$125 Copay	01	10a;		2		1	125.00	125.00	2		2		
H9615	010	0	1	04	01	H9615_010_0	9	1	40%	01	6;8a1;8a2;8b1;8b2;9a;9b;11a;11b;11c;15;17b;		2		2			2		1	40	40
H9615	010	0	1	04	01	H9615_010_0	9	2	$60 Copay	11	3-1;3-2;3-3;5;7a;7c;7d;7e;7f;7g;7h;7i;8b3;9c;16b;17a;18a;	17a;18a;	2		1	60.00	60.00	2		2		
H9615	010	0	1	04	01	H9615_010_0	9	3	$20	01	7b;		2		1	20.00	20.00	2		2		
H9615	010	0	1	04	01	H9615_010_0	9	4	$0	11	9d;12;14a;14d;14e;	9d;	2		1	0.00	0.00	2		2		
H9615	010	0	1	04	01	H9615_010_0	9	5	$200 Copay	01	10a;		2		1	200.00	200.00	2		2		
H9615	010	0	1	04	01	H9615_010_0	9	6	Hearing Aids	10		18b;	2		1	999.00	1399.00	2		2		
H9615	010	0	1	04	01	H9615_010_0	9	7	HealthDollars	10		14c;	1	100.00	2			2		2		
H9615	802	0	1	04	01	H9615_802_0	3	1		01	6;14a;		2		2			2		1	0	0
H9615	802	0	1	04	01	H9615_802_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H9615	807	0	1	04	01	H9615_807_0	6	1		01	6;14a;		2		2			2		1	0	0
H9615	807	0	1	04	01	H9615_807_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H9615	810	0	1	04	01	H9615_810_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H9615	810	0	1	04	01	H9615_810_0	3	1		01	6;14a;		2		2			2		1	0	0
H9615	811	0	1	04	01	H9615_811_0	6	1		01	6;14a;		2		2			2		1	0	0
H9615	811	0	1	04	01	H9615_811_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H9808	004	0	1	04	01	H9808_004_0	5	1	$20 copay	01	7b;		2		1	20.00	20.00	2		2		
H9808	004	0	1	04	01	H9808_004_0	5	9	$200 Copay	01	9b;10a;		2		1	200.00	200.00	2		2		
H9808	004	0	1	04	01	H9808_004_0	5	11	$10 to $25 Copay	01	8a1;8a2;8b3;		2		1	10.00	25.00	2		2		
H9808	004	0	1	04	01	H9808_004_0	5	12	$75 to $250 Copay	01	8b1;		2		1	75.00	250.00	2		2		
H9808	004	0	1	04	01	H9808_004_0	5	13	20% Coinsurance	01	11c;14d;14e;		2		2			2		1	20	20
H9808	004	0	1	04	01	H9808_004_0	5	14	30% Coinsurance	01	8b2;9d;11a;11b;15;		2		2			2		1	30	30
H9808	004	0	1	04	01	H9808_004_0	5	15	50% Coinsurance	01	17b;		2		2			2		1	50	50
H9808	004	0	1	04	01	H9808_004_0	5	2	$25 copay	01	3-1;3-2;3-3;		2		1	25.00	25.00	2		2		
H9808	004	0	1	04	01	H9808_004_0	5	3	$30 copay	11	14a;	14c;	2		1	30.00	30.00	2		2		
H9808	004	0	1	04	01	H9808_004_0	5	4	$40 copay	01	7a;7c;7i;		2		1	40.00	40.00	2		2		
H9808	004	0	1	04	01	H9808_004_0	5	5	$45 Copay	01	6;		2		1	45.00	45.00	2		2		
H9808	004	0	1	04	01	H9808_004_0	5	6	$50 Copay	01	7d;7f;7g;16b;17a;18a;		2		1	50.00	50.00	2		2		
H9808	004	0	1	04	01	H9808_004_0	5	7	$60 Copay	01	7e;7h;9c;12;		2		1	60.00	60.00	2		2		
H9808	004	0	1	04	01	H9808_004_0	5	8	$150 Copay	01	5;		2		1	150.00	150.00	2		2		
H9808	004	0	1	04	01	H9808_004_0	5	10	$250 Copay	01	9a;		2		1	250.00	250.00	2		2		
H9808	005	0	1	04	01	H9808_005_0	6	1	$20 Copay	01	3-1;3-2;3-3;7b;		2		1	20.00	20.00	2		2		
H9808	005	0	1	04	01	H9808_005_0	6	9	$10 to $25 Copay	01	8a1;8a2;8b3;		2		1	10.00	25.00	2		2		
H9808	005	0	1	04	01	H9808_005_0	6	10	$75 to $200 Copay	01	8b1;		2		1	75.00	200.00	2		2		
H9808	005	0	1	04	01	H9808_005_0	6	11	20% Coinsurance	01	11c;14d;14e;		2		2			2		1	20	20
H9808	005	0	1	04	01	H9808_005_0	6	12	30% Coinsurance	01	8b2;9d;11a;11b;15;		2		2			2		1	30	30
H9808	005	0	1	04	01	H9808_005_0	6	13	50% Coinsurance	01	17b;		2		2			2		1	50	50
H9808	005	0	1	04	01	H9808_005_0	6	14	50% Coinsurance	10		17b;	2		2			2		1	50	50
H9808	005	0	1	04	01	H9808_005_0	6	15	$50 Copay	01	7d;7f;7g;		2		1	50.00	50.00	2		2		
H9808	005	0	1	04	01	H9808_005_0	6	2	$30 Copay	11	7a;7c;7i;14a;	14c;	2		1	30.00	30.00	2		2		
H9808	005	0	1	04	01	H9808_005_0	6	3	$40 Copay	11	6;16b;17a;18a;	17a;	2		1	40.00	40.00	2		2		
H9808	005	0	1	04	01	H9808_005_0	6	4	$55 Copay	01	7e;7h;9c;12;		2		1	55.00	55.00	2		2		
H9808	005	0	1	04	01	H9808_005_0	6	5	$100 Copay	01	10a;		2		1	100.00	100.00	2		2		
H9808	005	0	1	04	01	H9808_005_0	6	6	$125 Copay	01	5;		2		1	125.00	125.00	2		2		
H9808	005	0	1	04	01	H9808_005_0	6	7	$175 Copay	01	9b;		2		1	175.00	175.00	2		2		
H9808	005	0	1	04	01	H9808_005_0	6	8	$225 Copay	01	9a;		2		1	225.00	225.00	2		2		
H9808	804	0	1	04	01	H9808_804_0	6	1		01	6;14a;		2		2			2		1	0	0
H9808	804	0	1	04	01	H9808_804_0	6	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H9947	005	1	1	04	01	H9947_005_1	10	3	Ambulance	01	10a;		2		1	250.00	250.00	2		1	20	20
H9947	005	1	1	04	01	H9947_005_1	10	2	20%	11	8b2;12;	16a;18a;	2		2			2		1	20	20
H9947	005	1	1	04	01	H9947_005_1	10	1	$0	11	9d;16b;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H9947	005	1	1	04	01	H9947_005_1	10	4	Diag/Rad	01	8a1;8a2;8b1;8b3;		2		2			2		1	40	40
H9947	005	1	1	04	01	H9947_005_1	10	5	PCP	01	7a;7g;		2		1	35.00	35.00	2		2		
H9947	005	1	1	04	01	H9947_005_1	10	6	Specialist	11	7b;7c;7d;7e;7f;7h;7i;	14b;	2		1	60.00	60.00	2		2		
H9947	005	1	1	04	01	H9947_005_1	10	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;		2		2			2		1	40	40
H9947	005	1	1	04	01	H9947_005_1	10	8	$0	10		14c;	1	95.00	1	0.00	0.00	2		2		
H9947	005	2	1	04	01	H9947_005_2	10	3	Ambulance	01	10a;		2		1	250.00	250.00	2		1	20	20
H9947	005	2	1	04	01	H9947_005_2	10	2	20%	11	8b2;12;	16a;18a;	2		2			2		1	20	20
H9947	005	2	1	04	01	H9947_005_2	10	1	$0	11	9d;16b;17b;	9d;17a;	2		1	0.00	0.00	2		2		
H9947	005	2	1	04	01	H9947_005_2	10	4	Diag/Rad	01	8a1;8a2;8b1;8b3;		2		2			2		1	40	40
H9947	005	2	1	04	01	H9947_005_2	10	8	$0	10		14c;	1	95.00	1	0.00	0.00	2		2		
H9947	005	2	1	04	01	H9947_005_2	10	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;		2		2			2		1	40	40
H9947	005	2	1	04	01	H9947_005_2	10	6	Specialist	11	7b;7c;7d;7e;7f;7h;7i;	14b;	2		1	60.00	60.00	2		2		
H9947	005	2	1	04	01	H9947_005_2	10	5	PCP	01	7a;7g;		2		1	35.00	35.00	2		2		
H9947	801	0	1	04	01	H9947_801_0	4	1		01	6;14a;		2		2			2		1	0	0
H9947	801	0	1	04	01	H9947_801_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H9947	802	0	1	04	01	H9947_802_0	4	1		01	6;14a;		2		2			2		1	0	0
H9947	802	0	1	04	01	H9947_802_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H9947	803	0	1	04	01	H9947_803_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
H9947	803	0	1	04	01	H9947_803_0	4	1		01	6;14a;		2		2			2		1	0	0
H9947	805	0	2	04	01	H9947_805_0	4	1		01	6;14a;		2		2			2		1	0	0
H9947	805	0	2	04	01	H9947_805_0	4	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R3175	003	0	1	31	11	R3175_003_0	4	3	Group 3	11	8a2;17b;	14c;16a;16b;	2		1	0.00	0.00	2		2		
R3175	003	0	1	31	11	R3175_003_0	4	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;16b;17a;18a;	7f;9d;	2		2			2		1	30	30
R3175	003	0	1	31	11	R3175_003_0	4	2	Group 2	01	14a;		2		2			2		1	0	30
R3175	003	0	1	31	11	R3175_003_0	4	4	Group 4	01	10a;12;15;		2		2			2		1	20	20
R3175	003	0	1	31	11	R3175_003_0	4	5	Group 5	10		13b;	1	95.00	1	0.00	0.00	2		2		
R3175	801	0	1	31	11	R3175_801_0	2	1		01	6;14a;		2		2			2		1	0	0
R3175	801	0	1	31	11	R3175_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R3175	802	0	1	31	11	R3175_802_0	2	1		01	6;14a;		2		2			2		1	0	0
R3175	802	0	1	31	11	R3175_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R3332	001	0	1	31	11	R3332_001_0	6	1	50%	01	3-1;3-2;3-3;6;7a;7b;7c;7d;7f;7g;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9d;11a;11b;11c;14a;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	50	50
R3332	001	0	1	31	11	R3332_001_0	6	4	Dialysis	01	12;		2		2			2		1	20	20
R3332	001	0	1	31	11	R3332_001_0	6	3	Ambulance	01	10a;		2		1	250.00	250.00	2		2		
R3332	001	0	1	31	11	R3332_001_0	6	2	Mental Health	01	5;7e;7h;9c;		2		1	40.00	40.00	2		2		
R3444	008	0	1	31	11	R3444_008_0	4	1	Group 1	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;12;15;16b;17b;18a;	9d;	2		2			2		1	20	20
R3444	008	0	1	31	11	R3444_008_0	4	2	Group 2	11	6;14a;14d;14e;	7f;10b;14c;16a;16b;17a;17b;18a;	2		1	0.00	0.00	2		2		
R3444	008	0	1	31	11	R3444_008_0	4	5	Group 5	10		13b;	1	35.00	1	0.00	0.00	2		2		
R3444	008	0	1	31	11	R3444_008_0	4	4	Group 4	01	17a;		2		2			2		1	0	20
R3444	008	0	1	31	11	R3444_008_0	4	3	Group 3	10		18b;	2		1	330.00	380.00	2		2		
R3444	008	0	1	31	11	R3444_008_0	4	6	Group 6	01	11c;		2		2			2		1	20	30
R3444	009	0	1	31	11	R3444_009_0	2	15	Group 15	10		17a;	2		1	25.00	25.00	2		2		
R3444	009	0	1	31	11	R3444_009_0	2	14	Group 14	01	7g;		2		1	15.00	45.00	2		2		
R3444	009	0	1	31	11	R3444_009_0	2	13	Group 13	01	10a;		2		1	250.00	250.00	2		2		
R3444	009	0	1	31	11	R3444_009_0	2	12	Group 12	10		18b;	2		1	390.00	450.00	2		2		
R3444	009	0	1	31	11	R3444_009_0	2	11	Group 11	11	7f;9d;14a;14d;14e;17b;	7f;9d;10b;14c;16b;17b;	2		1	0.00	0.00	2		2		
R3444	009	0	1	31	11	R3444_009_0	2	10	Group 10	01	17a;		2		1	0.00	45.00	2		2		
R3444	009	0	1	31	11	R3444_009_0	2	1	Group 1	01	3-1;3-2;3-3;7d;16b;		2		1	45.00	45.00	2		2		
R3444	009	0	1	31	11	R3444_009_0	2	2	Group 2	01	6;11a;		2		2			2		1	50	50
R3444	009	0	1	31	11	R3444_009_0	2	9	Group 9	01	8a1;8a2;8b1;8b2;8b3;		2		1	14.00	16.00	2		1	20	20
R3444	009	0	1	31	11	R3444_009_0	2	8	Group 8	01	9a;9b;11b;11c;12;15;		2		2			2		1	20	20
R3444	009	0	1	31	11	R3444_009_0	2	7	Group 7	11	7a;18a;	18a;	2		1	15.00	15.00	2		2		
R3444	009	0	1	31	11	R3444_009_0	2	6	Group 6	01	7e;7h;9c;		2		1	30.00	40.00	2		2		
R3444	009	0	1	31	11	R3444_009_0	2	5	Group 5	01	7c;7i;		2		1	40.00	40.00	2		2		
R3444	009	0	1	31	11	R3444_009_0	2	4	Group 4	11	7b;	16a;	2		1	20.00	20.00	2		2		
R3444	009	0	1	31	11	R3444_009_0	2	3	Group 3	01	5;		2		1	55.00	55.00	2		2		
R3444	011	0	1	31	11	R3444_011_0	4	4	Group  4	10		18b;	2		1	330.00	380.00	2		2		
R3444	011	0	1	31	11	R3444_011_0	4	3	Group 3	01	17a;		2		2			2		1	0	20
R3444	011	0	1	31	11	R3444_011_0	4	2	Group 2	11	6;14a;14d;14e;	7f;10b;14c;16a;16b;17a;17b;18a;	2		1	0.00	0.00	2		2		
R3444	011	0	1	31	11	R3444_011_0	4	1	Group 1	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;12;15;16b;17b;18a;	9d;	2		2			2		1	20	20
R3444	011	0	1	31	11	R3444_011_0	4	5	Group 5	01	11c;		2		2			2		1	20	30
R3444	012	0	1	31	11	R3444_012_0	2	14	Group 14	01	17a;		2		1	0.00	50.00	2		2		
R3444	012	0	1	31	11	R3444_012_0	2	15	Group 15	01	7g;		2		1	30.00	50.00	2		2		
R3444	012	0	1	31	11	R3444_012_0	2	8	Group 8	01	9a;9b;11b;11c;12;15;		2		2			2		1	20	20
R3444	012	0	1	31	11	R3444_012_0	2	7	Group 7	10		17a;	2		1	25.00	25.00	2		2		
R3444	012	0	1	31	11	R3444_012_0	2	6	Group 6	01	7e;7h;9c;		2		1	30.00	40.00	2		2		
R3444	012	0	1	31	11	R3444_012_0	2	5	Group 5	01	7c;7i;		2		1	40.00	40.00	2		2		
R3444	012	0	1	31	11	R3444_012_0	2	4	Group 4	01	7a;		2		1	30.00	30.00	2		2		
R3444	012	0	1	31	11	R3444_012_0	2	3	Group 3	01	5;		2		1	55.00	55.00	2		2		
R3444	012	0	1	31	11	R3444_012_0	2	2	Group 2	01	6;11a;		2		2			2		1	50	50
R3444	012	0	1	31	11	R3444_012_0	2	9	Group 9	01	8a1;8a2;8b1;8b2;8b3;		2		1	16.00	19.00	2		1	20	20
R3444	012	0	1	31	11	R3444_012_0	2	12	Group 12	10		18b;	2		1	390.00	450.00	2		2		
R3444	012	0	1	31	11	R3444_012_0	2	11	Group 11	11	9d;14a;14d;14e;17b;	9d;14b;14c;16b;17b;	2		1	0.00	0.00	2		2		
R3444	012	0	1	31	11	R3444_012_0	2	10	Group 10	11	7b;18a;	16a;18a;	2		1	20.00	20.00	2		2		
R3444	012	0	1	31	11	R3444_012_0	2	1	Group 1	11	3-1;3-2;3-3;7d;7f;16b;	7f;	2		1	50.00	50.00	2		2		
R3444	012	0	1	31	11	R3444_012_0	2	13	Group 13	01	10a;		2		1	250.00	250.00	2		2		
R5287	001	0	1	31	11	R5287_001_0	2	11	Group 11	01	14a;		2		2			2		1	0	40
R5287	001	0	1	31	11	R5287_001_0	2	10	Group 10	01	6;11a;15;		2		2			2		1	50	50
R5287	001	0	1	31	11	R5287_001_0	2	1	Group 1	11	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;18a;	7f;17a;18a;	2		1	70.00	70.00	2		2		
R5287	001	0	1	31	11	R5287_001_0	2	12	Group 12	01	7a;		2		1	45.00	45.00	2		2		
R5287	001	0	1	31	11	R5287_001_0	2	13	Group 13	01	7g;		2		1	45.00	70.00	2		2		
R5287	001	0	1	31	11	R5287_001_0	2	14	Group 14	01	8b3;		2		1	21.00	21.00	2		2		
R5287	001	0	1	31	11	R5287_001_0	2	9	Group 9	11	9d;	9d;14c;	2		1	0.00	0.00	2		2		
R5287	001	0	1	31	11	R5287_001_0	2	3	Group 3	01	8a2;		2		1	7.00	7.00	2		2		
R5287	001	0	1	31	11	R5287_001_0	2	4	Group 4	10		18b;	2		1	330.00	380.00	2		2		
R5287	001	0	1	31	11	R5287_001_0	2	5	Group 5	01	5;		2		1	75.00	75.00	2		2		
R5287	001	0	1	31	11	R5287_001_0	2	6	Group 6	01	10a;		2		1	275.00	275.00	2		2		
R5287	001	0	1	31	11	R5287_001_0	2	7	Group 7	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
R5287	001	0	1	31	11	R5287_001_0	2	8	Group 8	01	12;		2		2			2		1	20	20
R5287	001	0	1	31	11	R5287_001_0	2	2	Group 2	11	8a1;8b1;8b2;9a;9b;11b;11c;14d;14e;17b;	14b;	2		2			2		1	40	40
R5287	002	0	1	31	11	R5287_002_0	2	11	Group 11	01	14a;		2		2			2		1	0	40
R5287	002	0	1	31	11	R5287_002_0	2	10	Group 10	01	6;11a;15;		2		2			2		1	50	50
R5287	002	0	1	31	11	R5287_002_0	2	1	Group 1	11	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;18a;	7f;17a;18a;	2		1	70.00	70.00	2		2		
R5287	002	0	1	31	11	R5287_002_0	2	12	Group 12	01	7a;		2		1	45.00	45.00	2		2		
R5287	002	0	1	31	11	R5287_002_0	2	9	Group 9	11	9d;	9d;14c;	2		1	0.00	0.00	2		2		
R5287	002	0	1	31	11	R5287_002_0	2	8	Group 8	01	12;		2		2			2		1	20	20
R5287	002	0	1	31	11	R5287_002_0	2	7	Group 7	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
R5287	002	0	1	31	11	R5287_002_0	2	6	Group 6	01	10a;		2		1	275.00	275.00	2		2		
R5287	002	0	1	31	11	R5287_002_0	2	5	Group 5	01	5;		2		1	75.00	75.00	2		2		
R5287	002	0	1	31	11	R5287_002_0	2	4	Group 4	10		18b;	2		1	330.00	380.00	2		2		
R5287	002	0	1	31	11	R5287_002_0	2	13	Group 13	01	7g;		2		1	45.00	70.00	2		2		
R5287	002	0	1	31	11	R5287_002_0	2	14	Group 14	01	8b3;		2		1	4.00	4.00	2		2		
R5287	002	0	1	31	11	R5287_002_0	2	2	Group 2	11	8a1;8b1;8b2;9a;9b;11b;11c;14d;14e;17b;	14b;	2		2			2		1	40	40
R5287	002	0	1	31	11	R5287_002_0	2	3	Group 3	01	8a2;		2		1	5.00	5.00	2		2		
R5287	003	0	1	31	11	R5287_003_0	3	2	Group 2	01	14a;		2		2			2		1	0	40
R5287	003	0	1	31	11	R5287_003_0	3	1	Group 1	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;14d;14e;15;16b;17a;18a;	7f;9d;	2		2			2		1	40	40
R5287	003	0	1	31	11	R5287_003_0	3	6	Group 6	10		10b;	2		2			2		1	75	75
R5287	003	0	1	31	11	R5287_003_0	3	5	Group 5	10		16a;	2		1	40.00	40.00	2		2		
R5287	003	0	1	31	11	R5287_003_0	3	4	Group 4	11	8a2;17b;	14c;	2		1	0.00	0.00	2		2		
R5287	003	0	1	31	11	R5287_003_0	3	3	Group 3	01	10a;12;		2		2			2		1	20	20
R5287	003	0	1	31	11	R5287_003_0	3	7	Group 7	10		13b;	1	60.00	1	0.00	0.00	2		2		
R5342	001	0	1	31	11	R5342_001_0	2	1	Group 1	01	7a;		2		1	45.00	45.00	2		2		
R5342	001	0	1	31	11	R5342_001_0	2	12	Group 12	01	6;11a;		2		2			2		1	50	50
R5342	001	0	1	31	11	R5342_001_0	2	6	Group 6	01	5;		2		1	75.00	75.00	2		2		
R5342	001	0	1	31	11	R5342_001_0	2	5	Group 5	10		18b;	2		1	390.00	450.00	2		2		
R5342	001	0	1	31	11	R5342_001_0	2	4	Group 4	01	8a2;		2		1	19.00	19.00	2		2		
R5342	001	0	1	31	11	R5342_001_0	2	3	Group 3	11	8a1;8b1;8b2;9a;9b;11b;11c;14d;14e;15;17b;	14b;	2		2			2		1	40	40
R5342	001	0	1	31	11	R5342_001_0	2	2	Group 2	11	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;18a;	7f;17a;18a;	2		1	70.00	70.00	2		2		
R5342	001	0	1	31	11	R5342_001_0	2	10	Group 10	11	9d;	9d;14c;	2		1	0.00	0.00	2		2		
R5342	001	0	1	31	11	R5342_001_0	2	14	Group 14	01	8b3;		2		1	21.00	21.00	2		2		
R5342	001	0	1	31	11	R5342_001_0	2	13	Group 13	01	7g;		2		1	45.00	70.00	2		2		
R5342	001	0	1	31	11	R5342_001_0	2	8	Group 8	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
R5342	001	0	1	31	11	R5342_001_0	2	9	Group 9	01	12;		2		2			2		1	20	20
R5342	001	0	1	31	11	R5342_001_0	2	7	Group 7	01	10a;		2		1	250.00	250.00	2		2		
R5342	001	0	1	31	11	R5342_001_0	2	11	Group 11	01	14a;		2		2			2		1	0	40
R5342	002	0	1	31	11	R5342_002_0	2	11	Group 11	01	14a;		2		2			2		1	0	40
R5342	002	0	1	31	11	R5342_002_0	2	12	Group 12	01	6;11a;		2		2			2		1	50	50
R5342	002	0	1	31	11	R5342_002_0	2	13	Group 13	01	7g;		2		1	45.00	70.00	2		2		
R5342	002	0	1	31	11	R5342_002_0	2	14	Group 14	01	8b3;		2		1	21.00	21.00	2		2		
R5342	002	0	1	31	11	R5342_002_0	2	2	Group 2	11	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;18a;	7f;17a;18a;	2		1	70.00	70.00	2		2		
R5342	002	0	1	31	11	R5342_002_0	2	3	Group 3	11	8a1;8b1;8b2;9a;9b;11b;11c;14d;14e;15;17b;	14b;	2		2			2		1	40	40
R5342	002	0	1	31	11	R5342_002_0	2	1	Group 1	01	7a;		2		1	45.00	45.00	2		2		
R5342	002	0	1	31	11	R5342_002_0	2	5	Group 5	10		18b;	2		1	330.00	380.00	2		2		
R5342	002	0	1	31	11	R5342_002_0	2	6	Group 6	01	5;		2		1	75.00	75.00	2		2		
R5342	002	0	1	31	11	R5342_002_0	2	7	Group 7	01	10a;		2		1	250.00	250.00	2		2		
R5342	002	0	1	31	11	R5342_002_0	2	8	Group 8	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
R5342	002	0	1	31	11	R5342_002_0	2	9	Group 9	01	12;		2		2			2		1	20	20
R5342	002	0	1	31	11	R5342_002_0	2	10	Group 10	11	9d;	9d;14c;	2		1	0.00	0.00	2		2		
R5342	002	0	1	31	11	R5342_002_0	2	4	Group 4	01	8a2;		2		1	13.00	13.00	2		2		
R5342	005	0	1	31	11	R5342_005_0	2	6	Group 6	01	5;		2		1	75.00	75.00	2		2		
R5342	005	0	1	31	11	R5342_005_0	2	5	Group 5	10		18b;	2		1	390.00	450.00	2		2		
R5342	005	0	1	31	11	R5342_005_0	2	4	Group 4	01	8a2;		2		1	18.00	18.00	2		2		
R5342	005	0	1	31	11	R5342_005_0	2	3	Group 3	11	8a1;8b1;8b2;9a;9b;11b;11c;14d;14e;15;17b;	14b;	2		2			2		1	40	40
R5342	005	0	1	31	11	R5342_005_0	2	2	Group 2	11	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;18a;	7f;17a;18a;	2		1	60.00	60.00	2		2		
R5342	005	0	1	31	11	R5342_005_0	2	14	Group 14	01	8b3;		2		1	21.00	21.00	2		2		
R5342	005	0	1	31	11	R5342_005_0	2	12	Group 12	01	6;11a;		2		2			2		1	50	50
R5342	005	0	1	31	11	R5342_005_0	2	11	Group 11	01	14a;		2		2			2		1	0	40
R5342	005	0	1	31	11	R5342_005_0	2	10	Group 10	11	9d;	9d;14c;	2		1	0.00	0.00	2		2		
R5342	005	0	1	31	11	R5342_005_0	2	1	Group 1	01	7a;		2		1	40.00	40.00	2		2		
R5342	005	0	1	31	11	R5342_005_0	2	13	Group 13	01	7g;		2		1	40.00	60.00	2		2		
R5342	005	0	1	31	11	R5342_005_0	2	9	Group 9	01	12;		2		2			2		1	20	20
R5342	005	0	1	31	11	R5342_005_0	2	8	Group 8	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
R5342	005	0	1	31	11	R5342_005_0	2	7	Group 7	01	10a;		2		1	250.00	250.00	2		2		
R5342	006	0	1	31	11	R5342_006_0	2	1	Group 1	01	7a;		2		1	30.00	30.00	2		2		
R5342	006	0	1	31	11	R5342_006_0	2	10	Group 10	11	9d;	9d;14c;16a;16b;	2		1	0.00	0.00	2		2		
R5342	006	0	1	31	11	R5342_006_0	2	9	Group 9	01	12;		2		2			2		1	20	20
R5342	006	0	1	31	11	R5342_006_0	2	8	Group 8	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
R5342	006	0	1	31	11	R5342_006_0	2	7	Group 7	01	10a;		2		1	250.00	250.00	2		2		
R5342	006	0	1	31	11	R5342_006_0	2	6	Group 6	01	5;		2		1	75.00	75.00	2		2		
R5342	006	0	1	31	11	R5342_006_0	2	5	Group 5	10		18b;	2		1	390.00	450.00	2		2		
R5342	006	0	1	31	11	R5342_006_0	2	11	Group 11	01	14a;		2		2			2		1	0	40
R5342	006	0	1	31	11	R5342_006_0	2	12	Group 12	01	6;11a;		2		2			2		1	50	50
R5342	006	0	1	31	11	R5342_006_0	2	13	Group 13	01	7g;		2		1	30.00	50.00	2		2		
R5342	006	0	1	31	11	R5342_006_0	2	14	Group 14	01	8b3;		2		1	21.00	21.00	2		2		
R5342	006	0	1	31	11	R5342_006_0	2	2	Group 2	11	3-1;3-2;3-3;7b;7c;7d;7f;7i;16b;17a;18a;	7f;17a;18a;	2		1	50.00	50.00	2		2		
R5342	006	0	1	31	11	R5342_006_0	2	3	Group 3	11	8a1;8b1;8b2;9a;9b;11b;11c;14d;14e;15;17b;	14b;	2		2			2		1	40	40
R5342	006	0	1	31	11	R5342_006_0	2	4	Group 4	01	8a2;		2		1	19.00	19.00	2		2		
R5342	801	0	1	31	11	R5342_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5342	801	0	1	31	11	R5342_801_0	2	1		01	6;14a;		2		2			2		1	0	0
R5342	802	0	1	31	11	R5342_802_0	2	1		01	6;14a;		2		2			2		1	0	0
R5342	802	0	1	31	11	R5342_802_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5342	803	0	1	31	11	R5342_803_0	2	1		01	6;14a;		2		2			2		1	0	0
R5342	803	0	1	31	11	R5342_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	001	0	1	31	11	R5826_001_0	4	5		01	15;		2		2			2		1	20	40
R5826	001	0	1	31	11	R5826_001_0	4	6		01	11b;		2		2			2		1	25	25
R5826	001	0	1	31	11	R5826_001_0	4	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	40	40
R5826	001	0	1	31	11	R5826_001_0	4	8		10		13c;14c;	2		2			2		1	50	50
R5826	001	0	1	31	11	R5826_001_0	4	9		10		13b;	1	15.00	2			2		1	50	50
R5826	001	0	1	31	11	R5826_001_0	4	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
R5826	001	0	1	31	11	R5826_001_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	001	0	1	31	11	R5826_001_0	4	3		01	14a;		2		2			2		1	0	40
R5826	001	0	1	31	11	R5826_001_0	4	4		01	11a;11c;12;		2		2			2		1	20	20
R5826	002	0	1	31	11	R5826_002_0	4	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
R5826	002	0	1	31	11	R5826_002_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	002	0	1	31	11	R5826_002_0	4	3		01	14a;		2		2			2		1	0	20
R5826	002	0	1	31	11	R5826_002_0	4	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;12;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	20	20
R5826	002	0	1	31	11	R5826_002_0	4	5		10		13c;14c;16a;16b;	2		2			2		1	50	50
R5826	002	0	1	31	11	R5826_002_0	4	6		10		13b;	1	20.00	2			2		1	50	50
R5826	005	0	1	31	11	R5826_005_0	4	3		11	7a;7b;7d;7e;7f;7g;7h;14d;16b;17a;18a;	14b;	2		1	45.00	45.00	2		2		
R5826	005	0	1	31	11	R5826_005_0	4	4		01	12;		2		2			2		1	20	20
R5826	005	0	1	31	11	R5826_005_0	4	5		01	15;		2		2			2		1	20	40
R5826	005	0	1	31	11	R5826_005_0	4	6		01	11b;		2		2			2		1	25	25
R5826	005	0	1	31	11	R5826_005_0	4	7		01	11a;		2		2			2		1	30	30
R5826	005	0	1	31	11	R5826_005_0	4	8		01	5;6;9a;9b;11c;		2		2			2		1	40	40
R5826	005	0	1	31	11	R5826_005_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	005	0	1	31	11	R5826_005_0	4	13		10		13b;	1	25.00	2			2		1	50	50
R5826	005	0	1	31	11	R5826_005_0	4	9		01	14a;		2		1	0.00	45.00	2		1	40	40
R5826	005	0	1	31	11	R5826_005_0	4	11		11	3-1;3-2;3-3;7c;7i;8a1;8a2;8b2;8b3;9c;14e;	13d;	2		1	45.00	45.00	2		1	40	40
R5826	005	0	1	31	11	R5826_005_0	4	10		01	8b1;		2		1	45.00	175.00	2		1	40	40
R5826	005	0	1	31	11	R5826_005_0	4	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
R5826	005	0	1	31	11	R5826_005_0	4	12		10		14c;16a;16b;	2		2			2		1	50	50
R5826	006	0	1	31	11	R5826_006_0	4	6		01	11a;		2		2			2		1	30	30
R5826	006	0	1	31	11	R5826_006_0	4	5		10		18a;18b;	2		2			2		1	25	25
R5826	006	0	1	31	11	R5826_006_0	4	4		01	12;		2		2			2		1	20	20
R5826	006	0	1	31	11	R5826_006_0	4	3		01	14a;		2		2			2		1	0	50
R5826	006	0	1	31	11	R5826_006_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	006	0	1	31	11	R5826_006_0	4	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
R5826	006	0	1	31	11	R5826_006_0	4	7		01	11b;11c;		2		2			2		1	40	40
R5826	006	0	1	31	11	R5826_006_0	4	9		10		13b;	1	25.00	2			2		1	50	50
R5826	006	0	1	31	11	R5826_006_0	4	8		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;15;16b;17a;18a;	13c;13d;14b;14c;16a;16b;	2		2			2		1	50	50
R5826	007	0	1	31	11	R5826_007_0	5	3		01	14a;		2		2			2		1	0	30
R5826	007	0	1	31	11	R5826_007_0	5	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	007	0	1	31	11	R5826_007_0	5	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
R5826	007	0	1	31	11	R5826_007_0	5	4		01	8b2;11a;12;		2		2			2		1	20	20
R5826	007	0	1	31	11	R5826_007_0	5	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b3;9a;9b;9c;11b;11c;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
R5826	007	0	1	31	11	R5826_007_0	5	6		10		13c;14c;16a;	2		2			2		1	50	50
R5826	007	0	1	31	11	R5826_007_0	5	7		10		13b;	1	15.00	2			2		1	50	50
R5826	007	0	1	31	11	R5826_007_0	5	8		10		16b;	2		2			2		1	50	80
R5826	008	0	1	31	11	R5826_008_0	4	3		01	14a;		2		2			2		1	0	30
R5826	008	0	1	31	11	R5826_008_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	008	0	1	31	11	R5826_008_0	4	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
R5826	008	0	1	31	11	R5826_008_0	4	4		01	8b2;12;		2		2			2		1	20	20
R5826	008	0	1	31	11	R5826_008_0	4	9		10		16b;	2		2			2		1	50	75
R5826	008	0	1	31	11	R5826_008_0	4	8		10		13b;	1	20.00	2			2		1	50	50
R5826	008	0	1	31	11	R5826_008_0	4	7		10		13c;14c;16a;	2		2			2		1	50	50
R5826	008	0	1	31	11	R5826_008_0	4	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b3;9a;9b;9c;11a;11b;11c;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
R5826	008	0	1	31	11	R5826_008_0	4	5		10		18a;18b;	2		2			2		1	25	25
R5826	009	0	1	31	11	R5826_009_0	6	4		01	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8b1;8b2;8b3;9a;9b;9c;10a;11a;11b;11c;12;15;16b;17b;18a;		2		2			2		1	20	20
R5826	009	0	1	31	11	R5826_009_0	6	5		10		13c;14c;18a;	2		2			2		1	50	50
R5826	009	0	1	31	11	R5826_009_0	6	3		01	8a1;8a2;17a;		2		2			2		1	0	20
R5826	009	0	1	31	11	R5826_009_0	6	2		11	14a;14d;	13d;14b;	2		2			2		1	0	0
R5826	009	0	1	31	11	R5826_009_0	6	1		11	9d;14e;	9d;18b;	2		1	0.00	0.00	2		2		
R5826	009	0	1	31	11	R5826_009_0	6	6		10		13b;	1	25.00	2			2		1	50	50
R5826	010	0	1	31	11	R5826_010_0	4	9		10		13b;	1	20.00	2			2		1	50	50
R5826	010	0	1	31	11	R5826_010_0	4	8		10		13c;14c;16a;16b;	2		2			2		1	50	50
R5826	010	0	1	31	11	R5826_010_0	4	4		01	14a;		2		2			2		1	0	40
R5826	010	0	1	31	11	R5826_010_0	4	5		01	11a;11b;11c;		2		2			2		1	20	20
R5826	010	0	1	31	11	R5826_010_0	4	3		01	12;		2		2			2		1	0	20
R5826	010	0	1	31	11	R5826_010_0	4	6		01	15;		2		2			2		1	20	40
R5826	010	0	1	31	11	R5826_010_0	4	1		11	9d;	9d;17a;	2		1	0.00	0.00	2		2		
R5826	010	0	1	31	11	R5826_010_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	010	0	1	31	11	R5826_010_0	4	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;17b;18a;	13d;14b;	2		2			2		1	40	40
R5826	011	0	1	31	11	R5826_011_0	5	9		01	9a;		2		1	275.00	275.00	2		2		
R5826	011	0	1	31	11	R5826_011_0	5	8		01	7d;7g;		2		1	15.00	45.00	2		2		
R5826	011	0	1	31	11	R5826_011_0	5	7		01	3-1;3-2;3-3;7a;7c;7i;		2		1	15.00	15.00	2		2		
R5826	011	0	1	31	11	R5826_011_0	5	6		01	8b3;		2		1	0.00	60.00	2		2		
R5826	011	0	1	31	11	R5826_011_0	5	5		01	9b;		2		1	225.00	225.00	2		2		
R5826	011	0	1	31	11	R5826_011_0	5	4		01	7b;		2		1	20.00	20.00	2		2		
R5826	011	0	1	31	11	R5826_011_0	5	3		01	8b1;		2		1	0.00	225.00	2		2		
R5826	011	0	1	31	11	R5826_011_0	5	2		01	8a1;8a2;17a;		2		1	0.00	100.00	2		2		
R5826	011	0	1	31	11	R5826_011_0	5	15		10		13b;	1	10.00	2			2		1	50	50
R5826	011	0	1	31	11	R5826_011_0	5	13		11	11a;11b;11c;12;15;	18a;18b;	2		2			2		1	20	25
R5826	011	0	1	31	11	R5826_011_0	5	14		10		13c;14c;16a;16b;	2		2			2		1	50	55
R5826	011	0	1	31	11	R5826_011_0	5	12		01	7f;8b2;9c;16b;18a;		2		1	40.00	60.00	2		2		
R5826	011	0	1	31	11	R5826_011_0	5	11		01	5;7e;7h;		2		1	40.00	40.00	2		2		
R5826	011	0	1	31	11	R5826_011_0	5	10		01	10a;		2		1	300.00	300.00	2		2		
R5826	011	0	1	31	11	R5826_011_0	5	1		11	6;9d;14a;14d;14e;17b;	9d;13d;14b;17a;	2		1	0.00	0.00	2		2		
R5826	012	0	1	31	11	R5826_012_0	4	8		10		13c;14c;16a;	2		2			2		1	50	50
R5826	012	0	1	31	11	R5826_012_0	4	9		10		13b;	1	25.00	2			2		1	50	50
R5826	012	0	1	31	11	R5826_012_0	4	10		10		16b;	2		2			2		1	50	55
R5826	012	0	1	31	11	R5826_012_0	4	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
R5826	012	0	1	31	11	R5826_012_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	012	0	1	31	11	R5826_012_0	4	6		01	11a;11b;11c;		2		2			2		1	25	25
R5826	012	0	1	31	11	R5826_012_0	4	5		01	8a1;15;		2		2			2		1	20	40
R5826	012	0	1	31	11	R5826_012_0	4	4		01	6;12;		2		2			2		1	20	20
R5826	012	0	1	31	11	R5826_012_0	4	3		01	14a;		2		2			2		1	0	50
R5826	012	0	1	31	11	R5826_012_0	4	7		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	40	40
R5826	013	0	1	31	11	R5826_013_0	4	9		10		13b;	1	20.00	2			2		1	50	50
R5826	013	0	1	31	11	R5826_013_0	4	8		10		13c;14c;	2		2			2		1	50	50
R5826	013	0	1	31	11	R5826_013_0	4	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
R5826	013	0	1	31	11	R5826_013_0	4	6		01	15;		2		2			2		1	20	30
R5826	013	0	1	31	11	R5826_013_0	4	4		01	14a;		2		2			2		1	0	30
R5826	013	0	1	31	11	R5826_013_0	4	3		01	12;		2		2			2		1	0	20
R5826	013	0	1	31	11	R5826_013_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	013	0	1	31	11	R5826_013_0	4	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
R5826	013	0	1	31	11	R5826_013_0	4	5		01	11a;11b;11c;		2		2			2		1	20	20
R5826	014	0	1	31	11	R5826_014_0	4	6		10		13b;	1	25.00	2			2		1	50	50
R5826	014	0	1	31	11	R5826_014_0	4	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;13d;14b;14c;	2		2			2		1	50	50
R5826	014	0	1	31	11	R5826_014_0	4	4		01	12;		2		2			2		1	20	20
R5826	014	0	1	31	11	R5826_014_0	4	3		01	14a;		2		2			2		1	0	50
R5826	014	0	1	31	11	R5826_014_0	4	2		01	10a;		2		1	350.00	350.00	2		2		
R5826	014	0	1	31	11	R5826_014_0	4	1		11	9d;	9d;17a;	2		1	0.00	0.00	2		2		
R5826	018	0	1	31	11	R5826_018_0	4	3		11	7a;7b;7d;7e;7f;7g;7h;14d;16b;17a;18a;	14b;	2		1	45.00	45.00	2		2		
R5826	018	0	1	31	11	R5826_018_0	4	4		01	11a;11b;12;		2		2			2		1	20	20
R5826	018	0	1	31	11	R5826_018_0	4	5		01	15;		2		2			2		1	20	30
R5826	018	0	1	31	11	R5826_018_0	4	6		10		18a;18b;	2		2			2		1	25	25
R5826	018	0	1	31	11	R5826_018_0	4	7		01	5;6;9a;9b;11c;		2		2			2		1	30	30
R5826	018	0	1	31	11	R5826_018_0	4	8		01	14a;		2		1	0.00	45.00	2		1	30	30
R5826	018	0	1	31	11	R5826_018_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	018	0	1	31	11	R5826_018_0	4	13		10		14c;	1	500.00	2			2		1	50	50
R5826	018	0	1	31	11	R5826_018_0	4	12		10		13b;	1	5.00	2			2		1	50	50
R5826	018	0	1	31	11	R5826_018_0	4	11		10		16a;16b;	2		2			2		1	50	50
R5826	018	0	1	31	11	R5826_018_0	4	10		01	8b1;		2		1	45.00	75.00	2		1	30	30
R5826	018	0	1	31	11	R5826_018_0	4	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
R5826	018	0	1	31	11	R5826_018_0	4	9		11	3-1;3-2;3-3;7c;7i;8a1;8a2;8b2;8b3;9c;14e;	13d;	2		1	45.00	45.00	2		1	30	30
R5826	021	0	1	31	11	R5826_021_0	4	1		11	9d;17b;	9d;17a;17b;18b;	2		1	0.00	0.00	2		2		
R5826	021	0	1	31	11	R5826_021_0	4	10		10		13b;	1	15.00	2			2		1	50	50
R5826	021	0	1	31	11	R5826_021_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	021	0	1	31	11	R5826_021_0	4	3		01	12;		2		2			2		1	0	20
R5826	021	0	1	31	11	R5826_021_0	4	4		01	14a;		2		2			2		1	0	30
R5826	021	0	1	31	11	R5826_021_0	4	8		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
R5826	021	0	1	31	11	R5826_021_0	4	7		01	8a1;15;		2		2			2		1	20	30
R5826	021	0	1	31	11	R5826_021_0	4	6		01	6;11b;11c;		2		2			2		1	20	20
R5826	021	0	1	31	11	R5826_021_0	4	5		01	11a;		2		2			2		1	17	17
R5826	021	0	1	31	11	R5826_021_0	4	9		10		13c;14c;16a;16b;18a;	2		2			2		1	50	50
R5826	023	0	1	31	11	R5826_023_0	4	5		10		13b;	1	25.00	2			2		1	50	50
R5826	023	0	1	31	11	R5826_023_0	4	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14a;14d;14e;15;16b;17a;18a;	13c;13d;14b;14c;16a;	2		2			2		1	50	50
R5826	023	0	1	31	11	R5826_023_0	4	3		01	11a;12;		2		2			2		1	20	20
R5826	023	0	1	31	11	R5826_023_0	4	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
R5826	023	0	1	31	11	R5826_023_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	026	0	1	31	11	R5826_026_0	4	7		10		13c;14c;	2		2			2		1	50	50
R5826	026	0	1	31	11	R5826_026_0	4	6		11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
R5826	026	0	1	31	11	R5826_026_0	4	5		01	15;		2		2			2		1	20	30
R5826	026	0	1	31	11	R5826_026_0	4	4		01	6;11a;11b;11c;12;		2		2			2		1	20	20
R5826	026	0	1	31	11	R5826_026_0	4	3		01	14a;		2		2			2		1	0	50
R5826	026	0	1	31	11	R5826_026_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	026	0	1	31	11	R5826_026_0	4	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
R5826	026	0	1	31	11	R5826_026_0	4	8		10		13b;	1	25.00	2			2		1	50	50
R5826	053	0	1	31	11	R5826_053_0	4	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
R5826	053	0	1	31	11	R5826_053_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	053	0	1	31	11	R5826_053_0	4	3		01	12;		2		2			2		1	0	20
R5826	053	0	1	31	11	R5826_053_0	4	7		10		13b;	1	15.00	2			2		1	50	50
R5826	053	0	1	31	11	R5826_053_0	4	5		10		18a;18b;	2		2			2		1	25	25
R5826	053	0	1	31	11	R5826_053_0	4	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14a;14d;14e;15;16b;17a;18a;	13c;13d;14b;14c;16a;16b;	2		2			2		1	50	50
R5826	053	0	1	31	11	R5826_053_0	4	4		01	11a;		2		2			2		1	20	20
R5826	062	0	1	31	11	R5826_062_0	4	9		10		13c;14c;16a;16b;	2		2			2		1	50	50
R5826	062	0	1	31	11	R5826_062_0	4	8		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
R5826	062	0	1	31	11	R5826_062_0	4	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
R5826	062	0	1	31	11	R5826_062_0	4	10		10		13b;	1	20.00	2			2		1	50	50
R5826	062	0	1	31	11	R5826_062_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	062	0	1	31	11	R5826_062_0	4	3		01	12;		2		2			2		1	0	20
R5826	062	0	1	31	11	R5826_062_0	4	4		01	14a;		2		2			2		1	0	30
R5826	062	0	1	31	11	R5826_062_0	4	7		10		18a;18b;	2		2			2		1	25	25
R5826	062	0	1	31	11	R5826_062_0	4	6		01	15;		2		2			2		1	20	30
R5826	062	0	1	31	11	R5826_062_0	4	5		01	11a;11b;11c;		2		2			2		1	20	20
R5826	063	0	1	31	11	R5826_063_0	6	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	063	0	1	31	11	R5826_063_0	6	1		11	9d;	9d;17a;17b;	2		1	0.00	0.00	2		2		
R5826	063	0	1	31	11	R5826_063_0	6	5		10		13c;14c;16a;16b;	2		2			2		1	50	50
R5826	063	0	1	31	11	R5826_063_0	6	4		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;	13d;14b;	2		2			2		1	20	20
R5826	063	0	1	31	11	R5826_063_0	6	3		01	14a;		2		2			2		1	0	20
R5826	063	0	1	31	11	R5826_063_0	6	6		10		13b;	1	15.00	2			2		1	50	50
R5826	064	0	1	31	11	R5826_064_0	5	8		01	9c;		2		1	40.00	40.00	2		1	30	30
R5826	064	0	1	31	11	R5826_064_0	5	7		01	14a;		2		1	0.00	45.00	2		1	30	30
R5826	064	0	1	31	11	R5826_064_0	5	6		01	5;6;9a;9b;11c;15;		2		2			2		1	30	30
R5826	064	0	1	31	11	R5826_064_0	5	5		01	11a;11b;12;		2		2			2		1	20	20
R5826	064	0	1	31	11	R5826_064_0	5	4		11	7a;7d;7f;7g;14d;16b;17a;18a;	13d;	2		1	45.00	45.00	2		2		
R5826	064	0	1	31	11	R5826_064_0	5	3		11	7b;7e;7h;	14b;	2		1	40.00	40.00	2		2		
R5826	064	0	1	31	11	R5826_064_0	5	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	064	0	1	31	11	R5826_064_0	5	11		10		13b;	1	15.00	2			2		1	50	50
R5826	064	0	1	31	11	R5826_064_0	5	10		10		13c;14c;16a;16b;	2		2			2		1	50	50
R5826	064	0	1	31	11	R5826_064_0	5	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
R5826	064	0	1	31	11	R5826_064_0	5	9		01	3-1;3-2;3-3;7c;7i;8a1;8a2;8b1;8b2;8b3;14e;		2		1	45.00	45.00	2		1	30	30
R5826	065	0	1	31	11	R5826_065_0	4	5		01	15;		2		2			2		1	20	30
R5826	065	0	1	31	11	R5826_065_0	4	4		01	11a;12;		2		2			2		1	20	20
R5826	065	0	1	31	11	R5826_065_0	4	3		01	14a;		2		2			2		1	0	30
R5826	065	0	1	31	11	R5826_065_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	065	0	1	31	11	R5826_065_0	4	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
R5826	065	0	1	31	11	R5826_065_0	4	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
R5826	065	0	1	31	11	R5826_065_0	4	7		10		13c;14c;16a;16b;	2		2			2		1	50	50
R5826	065	0	1	31	11	R5826_065_0	4	8		10		13b;	1	10.00	2			2		1	50	50
R5826	066	0	1	31	11	R5826_066_0	5	3		01	12;		2		2			2		1	0	20
R5826	066	0	1	31	11	R5826_066_0	5	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	066	0	1	31	11	R5826_066_0	5	11		10		16b;	2		2			2		1	50	75
R5826	066	0	1	31	11	R5826_066_0	5	10		10		13b;	1	20.00	2			2		1	50	50
R5826	066	0	1	31	11	R5826_066_0	5	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
R5826	066	0	1	31	11	R5826_066_0	5	4		01	14a;		2		2			2		1	0	30
R5826	066	0	1	31	11	R5826_066_0	5	9		10		13c;14c;16a;	2		2			2		1	50	50
R5826	066	0	1	31	11	R5826_066_0	5	8		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
R5826	066	0	1	31	11	R5826_066_0	5	7		10		18a;18b;	2		2			2		1	25	25
R5826	066	0	1	31	11	R5826_066_0	5	6		01	15;		2		2			2		1	20	30
R5826	066	0	1	31	11	R5826_066_0	5	5		01	11a;11b;11c;		2		2			2		1	20	20
R5826	067	0	1	31	11	R5826_067_0	4	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
R5826	067	0	1	31	11	R5826_067_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	067	0	1	31	11	R5826_067_0	4	7		10		13b;	1	25.00	2			2		1	50	50
R5826	067	0	1	31	11	R5826_067_0	4	6		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13c;13d;14b;14c;16a;	2		2			2		1	50	50
R5826	067	0	1	31	11	R5826_067_0	4	5		01	11a;15;		2		2			2		1	20	20
R5826	067	0	1	31	11	R5826_067_0	4	4		01	14a;		2		2			2		1	0	50
R5826	067	0	1	31	11	R5826_067_0	4	3		01	12;		2		2			2		1	0	20
R5826	067	0	1	31	11	R5826_067_0	4	8		10		16b;	2		2			2		1	50	55
R5826	068	0	1	31	11	R5826_068_0	4	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
R5826	068	0	1	31	11	R5826_068_0	4	10		11	8a1;8a2;8b3;14e;	13d;	2		1	35.00	50.00	2		1	30	30
R5826	068	0	1	31	11	R5826_068_0	4	11		01	8b1;8b2;9c;		2		1	50.00	50.00	2		1	30	30
R5826	068	0	1	31	11	R5826_068_0	4	12		10		13c;14c;16a;	2		2			2		1	50	50
R5826	068	0	1	31	11	R5826_068_0	4	13		10		13b;	1	20.00	2			2		1	50	50
R5826	068	0	1	31	11	R5826_068_0	4	14		10		16b;	2		2			2		1	50	55
R5826	068	0	1	31	11	R5826_068_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	068	0	1	31	11	R5826_068_0	4	3		11	7a;	14b;	2		1	35.00	35.00	2		2		
R5826	068	0	1	31	11	R5826_068_0	4	4		01	14d;		2		1	35.00	50.00	2		2		
R5826	068	0	1	31	11	R5826_068_0	4	5		01	7b;7d;7e;7f;7g;7h;16b;17a;18a;		2		1	50.00	50.00	2		2		
R5826	068	0	1	31	11	R5826_068_0	4	6		01	11a;12;		2		2			2		1	20	20
R5826	068	0	1	31	11	R5826_068_0	4	7		01	11c;		2		2			2		1	20	30
R5826	068	0	1	31	11	R5826_068_0	4	8		01	3-1;3-2;3-3;5;6;7c;7i;9a;9b;11b;15;		2		2			2		1	30	30
R5826	068	0	1	31	11	R5826_068_0	4	9		01	14a;		2		1	0.00	50.00	2		1	30	30
R5826	069	0	1	31	11	R5826_069_0	4	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
R5826	069	0	1	31	11	R5826_069_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	069	0	1	31	11	R5826_069_0	4	9		10		13b;	1	25.00	2			2		1	50	50
R5826	069	0	1	31	11	R5826_069_0	4	8		10		13c;14c;16a;16b;	2		2			2		1	50	50
R5826	069	0	1	31	11	R5826_069_0	4	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;11c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	40	40
R5826	069	0	1	31	11	R5826_069_0	4	6		01	15;		2		2			2		1	20	40
R5826	069	0	1	31	11	R5826_069_0	4	5		01	11a;		2		2			2		1	15	15
R5826	069	0	1	31	11	R5826_069_0	4	3		01	12;		2		2			2		1	0	20
R5826	069	0	1	31	11	R5826_069_0	4	4		01	14a;		2		2			2		1	0	40
R5826	070	0	1	31	11	R5826_070_0	4	3		01	14a;		2		2			2		1	0	50
R5826	070	0	1	31	11	R5826_070_0	4	2		01	10a;		2		1	350.00	350.00	2		2		
R5826	070	0	1	31	11	R5826_070_0	4	1		11	9d;	9d;17a;	2		1	0.00	0.00	2		2		
R5826	070	0	1	31	11	R5826_070_0	4	5		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11a;11b;11c;14d;14e;15;16b;17a;17b;18a;	13c;13d;14b;14c;	2		2			2		1	50	50
R5826	070	0	1	31	11	R5826_070_0	4	4		01	12;		2		2			2		1	20	20
R5826	070	0	1	31	11	R5826_070_0	4	6		10		13b;	1	25.00	2			2		1	50	50
R5826	074	0	1	31	11	R5826_074_0	4	9		11	5;6;9a;9b;11c;14d;14e;	13d;14b;14c;16a;16b;	2		2			2		1	50	50
R5826	074	0	1	31	11	R5826_074_0	4	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
R5826	074	0	1	31	11	R5826_074_0	4	10		01	8b1;		2		1	60.00	275.00	2		1	50	50
R5826	074	0	1	31	11	R5826_074_0	4	11		01	3-1;3-2;3-3;7c;7i;8a1;8a2;8b2;8b3;9c;17a;		2		1	60.00	60.00	2		1	50	50
R5826	074	0	1	31	11	R5826_074_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	074	0	1	31	11	R5826_074_0	4	3		01	7a;7b;7d;7e;7f;7g;7h;16b;18a;		2		1	60.00	60.00	2		2		
R5826	074	0	1	31	11	R5826_074_0	4	4		01	14a;		2		2			2		1	0	50
R5826	074	0	1	31	11	R5826_074_0	4	5		01	12;		2		2			2		1	20	20
R5826	074	0	1	31	11	R5826_074_0	4	6		01	15;		2		2			2		1	20	50
R5826	074	0	1	31	11	R5826_074_0	4	7		01	11b;		2		2			2		1	25	25
R5826	074	0	1	31	11	R5826_074_0	4	8		01	11a;		2		2			2		1	30	30
R5826	077	0	1	31	11	R5826_077_0	5	3		01	3-1;3-2;3-3;7a;7b;7c;7i;8b3;		2		1	20.00	95.00	2		2		
R5826	077	0	1	31	11	R5826_077_0	5	9		01	7f;16b;18a;		2		1	45.00	45.00	2		2		
R5826	077	0	1	31	11	R5826_077_0	5	15		10		13b;	1	15.00	2			2		1	50	50
R5826	077	0	1	31	11	R5826_077_0	5	14		10		13c;14c;16a;16b;	2		2			2		1	50	50
R5826	077	0	1	31	11	R5826_077_0	5	13		11	7d;7g;	18a;18b;	2		1	45.00	45.00	2		1	25	25
R5826	077	0	1	31	11	R5826_077_0	5	12		01	8a1;		2		1	0.00	95.00	2		1	25	25
R5826	077	0	1	31	11	R5826_077_0	5	11		01	8b2;11a;11b;11c;12;15;		2		2			2		1	20	20
R5826	077	0	1	31	11	R5826_077_0	5	10		01	9c;		2		1	40.00	95.00	2		2		
R5826	077	0	1	31	11	R5826_077_0	5	1		11	6;9d;14a;14d;14e;17b;	9d;13d;14b;17a;17b;	2		1	0.00	0.00	2		2		
R5826	077	0	1	31	11	R5826_077_0	5	4		01	9b;		2		1	235.00	235.00	2		2		
R5826	077	0	1	31	11	R5826_077_0	5	5		01	9a;		2		1	285.00	285.00	2		2		
R5826	077	0	1	31	11	R5826_077_0	5	6		01	10a;		2		1	300.00	300.00	2		2		
R5826	077	0	1	31	11	R5826_077_0	5	7		01	5;7e;7h;		2		1	40.00	40.00	2		2		
R5826	077	0	1	31	11	R5826_077_0	5	8		01	8b1;		2		1	45.00	285.00	2		2		
R5826	077	0	1	31	11	R5826_077_0	5	2		01	8a2;17a;		2		1	0.00	95.00	2		2		
R5826	078	0	1	31	11	R5826_078_0	5	8		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;11b;14d;14e;15;16b;17a;18a;	13d;14b;	2		2			2		1	30	30
R5826	078	0	1	31	11	R5826_078_0	5	7		01	11c;		2		2			2		1	25	30
R5826	078	0	1	31	11	R5826_078_0	5	6		10		18a;18b;	2		2			2		1	25	25
R5826	078	0	1	31	11	R5826_078_0	5	5		01	12;		2		2			2		1	20	20
R5826	078	0	1	31	11	R5826_078_0	5	4		01	11a;		2		2			2		1	18	18
R5826	078	0	1	31	11	R5826_078_0	5	3		01	14a;		2		2			2		1	0	30
R5826	078	0	1	31	11	R5826_078_0	5	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	078	0	1	31	11	R5826_078_0	5	10		10		13b;	1	10.00	2			2		1	50	50
R5826	078	0	1	31	11	R5826_078_0	5	1		11	9d;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
R5826	078	0	1	31	11	R5826_078_0	5	9		10		13c;14c;	2		2			2		1	50	50
R5826	079	0	1	31	11	R5826_079_0	5	1		11	6;9d;14a;14d;14e;17b;	9d;13d;14b;17a;	2		1	0.00	0.00	2		2		
R5826	079	0	1	31	11	R5826_079_0	5	10		01	7f;16b;18a;		2		1	45.00	45.00	2		2		
R5826	079	0	1	31	11	R5826_079_0	5	9		01	8b1;		2		1	45.00	295.00	2		2		
R5826	079	0	1	31	11	R5826_079_0	5	8		01	5;7e;7h;		2		1	40.00	40.00	2		2		
R5826	079	0	1	31	11	R5826_079_0	5	7		01	10a;		2		1	300.00	300.00	2		2		
R5826	079	0	1	31	11	R5826_079_0	5	6		01	9a;		2		1	295.00	295.00	2		2		
R5826	079	0	1	31	11	R5826_079_0	5	5		01	9b;		2		1	245.00	245.00	2		2		
R5826	079	0	1	31	11	R5826_079_0	5	4		01	7b;		2		1	20.00	20.00	2		2		
R5826	079	0	1	31	11	R5826_079_0	5	3		01	3-1;3-2;3-3;7a;7c;7d;7g;7i;8b3;		2		1	15.00	95.00	2		2		
R5826	079	0	1	31	11	R5826_079_0	5	2		01	8a1;8a2;17a;		2		1	0.00	95.00	2		2		
R5826	079	0	1	31	11	R5826_079_0	5	11		01	9c;		2		1	40.00	95.00	2		2		
R5826	079	0	1	31	11	R5826_079_0	5	12		01	11a;11b;11c;12;15;		2		2			2		1	20	20
R5826	079	0	1	31	11	R5826_079_0	5	13		01	8b2;		2		1	45.00	45.00	2		1	20	20
R5826	079	0	1	31	11	R5826_079_0	5	14		10		13c;14c;16a;16b;	2		2			2		1	50	50
R5826	079	0	1	31	11	R5826_079_0	5	15		10		13b;	1	15.00	2			2		1	50	50
R5826	091	0	1	31	11	R5826_091_0	4	3		01	14a;		2		2			2		1	0	50
R5826	091	0	1	31	11	R5826_091_0	4	2		01	10a;		2		1	300.00	300.00	2		2		
R5826	091	0	1	31	11	R5826_091_0	4	1		11	9d;17b;	9d;17a;	2		1	0.00	0.00	2		2		
R5826	091	0	1	31	11	R5826_091_0	4	8		10		13c;14c;	2		2			2		1	50	50
R5826	091	0	1	31	11	R5826_091_0	4	9		10		13b;	1	30.00	2			2		1	50	50
R5826	091	0	1	31	11	R5826_091_0	4	6		01	11b;11c;		2		2			2		1	25	25
R5826	091	0	1	31	11	R5826_091_0	4	5		01	15;		2		2			2		1	20	40
R5826	091	0	1	31	11	R5826_091_0	4	4		01	11a;12;		2		2			2		1	20	20
R5826	091	0	1	31	11	R5826_091_0	4	7		11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;14d;14e;16b;17a;18a;	13d;14b;	2		2			2		1	40	40
R5826	801	0	1	31	11	R5826_801_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	801	0	1	31	11	R5826_801_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	802	0	1	31	11	R5826_802_0	3	1		01	6;14a;		2		2			2		1	0	0
R5826	802	0	1	31	11	R5826_802_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	803	0	1	31	11	R5826_803_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	803	0	1	31	11	R5826_803_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	804	0	1	31	11	R5826_804_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	804	0	1	31	11	R5826_804_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	805	0	1	31	11	R5826_805_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	805	0	1	31	11	R5826_805_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	806	0	1	31	11	R5826_806_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	806	0	1	31	11	R5826_806_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	807	0	1	31	11	R5826_807_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	807	0	1	31	11	R5826_807_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	808	0	1	31	11	R5826_808_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	808	0	1	31	11	R5826_808_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	809	0	1	31	11	R5826_809_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	809	0	1	31	11	R5826_809_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	810	0	1	31	11	R5826_810_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	810	0	1	31	11	R5826_810_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	811	0	1	31	11	R5826_811_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	811	0	1	31	11	R5826_811_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	812	0	1	31	11	R5826_812_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	812	0	1	31	11	R5826_812_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	813	0	1	31	11	R5826_813_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	813	0	1	31	11	R5826_813_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	814	0	1	31	11	R5826_814_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	814	0	1	31	11	R5826_814_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	815	0	1	31	11	R5826_815_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	815	0	1	31	11	R5826_815_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	816	0	1	31	11	R5826_816_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	816	0	1	31	11	R5826_816_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	817	0	1	31	11	R5826_817_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	817	0	1	31	11	R5826_817_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	818	0	1	31	11	R5826_818_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	818	0	1	31	11	R5826_818_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	819	0	1	31	11	R5826_819_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	819	0	1	31	11	R5826_819_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	820	0	1	31	11	R5826_820_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	820	0	1	31	11	R5826_820_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	821	0	1	31	11	R5826_821_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	821	0	1	31	11	R5826_821_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	822	0	1	31	11	R5826_822_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	822	0	1	31	11	R5826_822_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	823	0	1	31	11	R5826_823_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	823	0	1	31	11	R5826_823_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	824	0	1	31	11	R5826_824_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	824	0	1	31	11	R5826_824_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	825	0	1	31	11	R5826_825_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	825	0	1	31	11	R5826_825_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	826	0	1	31	11	R5826_826_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	826	0	1	31	11	R5826_826_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	827	0	1	31	11	R5826_827_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	827	0	1	31	11	R5826_827_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	828	0	1	31	11	R5826_828_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	828	0	1	31	11	R5826_828_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	831	0	1	31	11	R5826_831_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	831	0	1	31	11	R5826_831_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	832	0	1	31	11	R5826_832_0	2	1		01	6;14a;		2		2			2		1	0	0
R5826	832	0	1	31	11	R5826_832_0	2	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	833	0	1	31	11	R5826_833_0	3	1		01	6;14a;		2		2			2		1	0	0
R5826	833	0	1	31	11	R5826_833_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	834	0	1	31	11	R5826_834_0	3	1		01	6;14a;		2		2			2		1	0	0
R5826	834	0	1	31	11	R5826_834_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	835	0	1	31	11	R5826_835_0	3	1		01	6;14a;		2		2			2		1	0	0
R5826	835	0	1	31	11	R5826_835_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	836	0	1	31	11	R5826_836_0	3	1		01	6;14a;		2		2			2		1	0	0
R5826	836	0	1	31	11	R5826_836_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	837	0	1	31	11	R5826_837_0	3	1		01	6;14a;		2		2			2		1	0	0
R5826	837	0	1	31	11	R5826_837_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	838	0	1	31	11	R5826_838_0	3	1		01	6;14a;		2		2			2		1	0	0
R5826	838	0	1	31	11	R5826_838_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	839	0	1	31	11	R5826_839_0	3	1		01	6;14a;		2		2			2		1	0	0
R5826	839	0	1	31	11	R5826_839_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	840	0	1	31	11	R5826_840_0	3	1		01	6;14a;		2		2			2		1	0	0
R5826	840	0	1	31	11	R5826_840_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	841	0	1	31	11	R5826_841_0	3	1		01	6;14a;		2		2			2		1	0	0
R5826	841	0	1	31	11	R5826_841_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	842	0	1	31	11	R5826_842_0	3	1		01	6;14a;		2		2			2		1	0	0
R5826	842	0	1	31	11	R5826_842_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	843	0	1	31	11	R5826_843_0	3	1		01	6;14a;		2		2			2		1	0	0
R5826	843	0	1	31	11	R5826_843_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5826	844	0	1	31	11	R5826_844_0	3	1		01	6;14a;		2		2			2		1	0	0
R5826	844	0	1	31	11	R5826_844_0	3	2		01	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;		2		2			2		1	20	20
R5941	013	0	1	31	11	R5941_013_0	11	3	Ambulance	01	10a;		2		1	150.00	150.00	2		1	20	20
R5941	013	0	1	31	11	R5941_013_0	11	2	20%	11	8b2;12;	16a;18a;	2		2			2		1	20	20
R5941	013	0	1	31	11	R5941_013_0	11	1	$0	11	9d;16b;17b;	9d;17a;17b;	2		1	0.00	0.00	2		2		
R5941	013	0	1	31	11	R5941_013_0	11	4	Diag/Rad	01	8a1;8a2;8b1;8b3;		2		2			2		1	30	30
R5941	013	0	1	31	11	R5941_013_0	11	5	PCP	01	7a;7g;		2		1	25.00	25.00	2		2		
R5941	013	0	1	31	11	R5941_013_0	11	6	Specialist	11	7b;7c;7d;7e;7f;7h;7i;	14b;	2		1	50.00	50.00	2		2		
R5941	013	0	1	31	11	R5941_013_0	11	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;		2		2			2		1	40	40
R5941	013	0	1	31	11	R5941_013_0	11	8	$0	10		14c;	1	95.00	1	0.00	0.00	2		2		
R5941	014	0	1	31	11	R5941_014_0	11	3	Ambulance	01	10a;		2		1	250.00	250.00	2		1	20	20
R5941	014	0	1	31	11	R5941_014_0	11	2	20%	11	8b2;12;	16a;18a;	2		2			2		1	20	20
R5941	014	0	1	31	11	R5941_014_0	11	1	$0	11	9d;16b;17b;	9d;17a;	2		1	0.00	0.00	2		2		
R5941	014	0	1	31	11	R5941_014_0	11	4	Diag/Rad	01	8a1;8a2;8b1;8b3;		2		2			2		1	30	30
R5941	014	0	1	31	11	R5941_014_0	11	8	$0	10		14c;	1	95.00	1	0.00	0.00	2		2		
R5941	014	0	1	31	11	R5941_014_0	11	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;15;17a;18a;		2		2			2		1	40	40
R5941	014	0	1	31	11	R5941_014_0	11	6	Specialist	11	7b;7c;7d;7e;7f;7h;7i;	14b;	2		1	60.00	60.00	2		2		
R5941	014	0	1	31	11	R5941_014_0	11	5	PCP	01	7a;7g;		2		1	40.00	40.00	2		2		
R5941	015	0	1	31	11	R5941_015_0	8	1	$0	11	9d;16b;17b;	9d;14c;17a;	2		1	0.00	0.00	2		2		
R5941	015	0	1	31	11	R5941_015_0	8	2	20%	11	8a2;8b2;12;15;	16a;18a;	2		2			2		1	20	20
R5941	015	0	1	31	11	R5941_015_0	8	6	SPEC	11	7b;7c;7d;7e;7f;7h;7i;	14b;	2		1	60.00	60.00	2		2		
R5941	015	0	1	31	11	R5941_015_0	8	5	PCP	01	7a;7g;		2		1	40.00	40.00	2		2		
R5941	015	0	1	31	11	R5941_015_0	8	4	Diag/Rad	01	8a1;8b1;8b3;		2		2			2		1	35	35
R5941	015	0	1	31	11	R5941_015_0	8	3	Ambulance	01	10a;		2		1	250.00	250.00	2		1	20	20
R5941	015	0	1	31	11	R5941_015_0	8	7	General	01	3-1;3-2;3-3;5;6;9a;9b;9c;11a;11b;11c;14a;14d;14e;17a;18a;		2		2			2		1	40	40
R6694	001	0	1	31	11	R6694_001_0	8	5	Hearing Aid Allowance	10		18b;	2		2			2		2		
R6694	001	0	1	31	11	R6694_001_0	8	4	Eyewear Allowance	10		17b;	2		2			2		2		
R6694	001	0	1	31	11	R6694_001_0	8	3	Dental	10		16a;16b;	2		2			2		2		
R6694	001	0	1	31	11	R6694_001_0	8	2	Ambulance	01	10a;		2		1	150.00	150.00	2		2		
R6694	001	0	1	31	11	R6694_001_0	8	1	20% OON Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	20	20
R6694	001	0	1	31	11	R6694_001_0	8	6	0% -$75 Tier	10		14c;	2		1	0.00	75.00	2		2		
R6694	001	0	1	31	11	R6694_001_0	8	7	Immunizations	01	14a;		2		2			2		1	0	20
R6694	003	0	1	31	11	R6694_003_0	9	5	Hearing Aid Allowance	10		18b;	2		2			2		2		
R6694	003	0	1	31	11	R6694_003_0	9	4	Eyewear Allowance	10		17b;	2		2			2		2		
R6694	003	0	1	31	11	R6694_003_0	9	6	0% -$75 Tier	10		14c;	2		1	0.00	75.00	2		2		
R6694	003	0	1	31	11	R6694_003_0	9	2	Ambulance	01	10a;		2		1	100.00	100.00	2		2		
R6694	003	0	1	31	11	R6694_003_0	9	1	20% OON Tier	11	3-1;3-2;3-3;5;6;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;11a;11b;11c;12;14d;14e;15;16b;17a;17b;18a;	9d;14b;17a;18a;	2		2			2		1	20	20
R6694	003	0	1	31	11	R6694_003_0	9	3	Dental	10		16a;16b;	2		2			2		2		
R6694	003	0	1	31	11	R6694_003_0	9	7	immunization	01	14a;		2		2			2		1	0	20
R6801	008	0	1	31	11	R6801_008_0	4	4	Group 4	01	17a;		2		2			2		1	0	20
R6801	008	0	1	31	11	R6801_008_0	4	3	Group 3	10		18b;	2		1	330.00	380.00	2		2		
R6801	008	0	1	31	11	R6801_008_0	4	2	Group 2	11	6;14a;14d;14e;	7f;10b;14c;16a;16b;17a;17b;18a;	2		1	0.00	0.00	2		2		
R6801	008	0	1	31	11	R6801_008_0	4	1	Group 1	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;12;15;16b;17b;18a;	9d;	2		2			2		1	20	20
R6801	008	0	1	31	11	R6801_008_0	4	5	Group 5	01	11c;		2		2			2		1	20	30
R6801	008	0	1	31	11	R6801_008_0	4	6	Group 6	10		13b;	1	110.00	1	0.00	0.00	2		2		
R6801	009	0	1	31	11	R6801_009_0	2	9	Group 9	01	8a1;8a2;8b1;8b2;8b3;		2		1	13.00	16.00	2		1	20	20
R6801	009	0	1	31	11	R6801_009_0	2	8	Group 8	01	9a;9b;11b;11c;12;15;		2		2			2		1	20	20
R6801	009	0	1	31	11	R6801_009_0	2	7	Group 7	10		18b;	2		1	330.00	380.00	2		2		
R6801	009	0	1	31	11	R6801_009_0	2	6	Group 6	01	7e;7h;9c;		2		1	30.00	40.00	2		2		
R6801	009	0	1	31	11	R6801_009_0	2	5	Group 5	01	7g;		2		1	15.00	45.00	2		2		
R6801	009	0	1	31	11	R6801_009_0	2	4	Group 4	11	7a;18a;	18a;	2		1	15.00	15.00	2		2		
R6801	009	0	1	31	11	R6801_009_0	2	3	Group 3	01	6;11a;		2		2			2		1	50	50
R6801	009	0	1	31	11	R6801_009_0	2	2	Group 2	01	5;		2		1	55.00	55.00	2		2		
R6801	009	0	1	31	11	R6801_009_0	2	15	Group 15	10		17a;	2		1	25.00	25.00	2		2		
R6801	009	0	1	31	11	R6801_009_0	2	14	Group 14	01	7c;7i;		2		1	40.00	40.00	2		2		
R6801	009	0	1	31	11	R6801_009_0	2	11	Group 11	11	7f;9d;14a;14d;14e;17b;	7f;9d;10b;14c;16a;16b;17b;	2		1	0.00	0.00	2		2		
R6801	009	0	1	31	11	R6801_009_0	2	12	Group 12	01	17a;		2		1	0.00	45.00	2		2		
R6801	009	0	1	31	11	R6801_009_0	2	13	Group 13	01	7b;		2		1	20.00	20.00	2		2		
R6801	009	0	1	31	11	R6801_009_0	2	10	Group 10	01	10a;		2		1	250.00	250.00	2		2		
R6801	009	0	1	31	11	R6801_009_0	2	1	Group 1	01	3-1;3-2;3-3;7d;16b;		2		1	45.00	45.00	2		2		
R6801	011	0	1	31	11	R6801_011_0	4	5	Group 5	01	11c;		2		2			2		1	20	30
R6801	011	0	1	31	11	R6801_011_0	4	6	Group 6	10		13b;	1	45.00	1	0.00	0.00	2		2		
R6801	011	0	1	31	11	R6801_011_0	4	1	Group 1	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;12;15;16b;17b;18a;	9d;	2		2			2		1	20	20
R6801	011	0	1	31	11	R6801_011_0	4	2	Group 2	11	6;14a;14d;14e;	10b;14c;18a;	2		1	0.00	0.00	2		2		
R6801	011	0	1	31	11	R6801_011_0	4	3	Group 3	01	17a;		2		2			2		1	0	20
R6801	011	0	1	31	11	R6801_011_0	4	4	Group  4	10		18b;	2		1	330.00	380.00	2		2		
R6801	012	0	1	31	11	R6801_012_0	2	14	Group 14	01	7c;7i;		2		1	40.00	40.00	2		2		
R6801	012	0	1	31	11	R6801_012_0	2	13	Group 13	01	10a;		2		1	250.00	250.00	2		2		
R6801	012	0	1	31	11	R6801_012_0	2	12	Group 12	10		18b;	2		1	330.00	380.00	2		2		
R6801	012	0	1	31	11	R6801_012_0	2	11	Group 11	11	9d;14a;14d;14e;17b;	9d;14b;14c;16b;17b;	2		1	0.00	0.00	2		2		
R6801	012	0	1	31	11	R6801_012_0	2	10	Group 10	01	17a;		2		1	0.00	45.00	2		2		
R6801	012	0	1	31	11	R6801_012_0	2	1	Group 1	11	3-1;3-2;3-3;7d;7f;16b;	7f;	2		1	45.00	45.00	2		2		
R6801	012	0	1	31	11	R6801_012_0	2	7	Group 7	10		17a;	2		1	25.00	25.00	2		2		
R6801	012	0	1	31	11	R6801_012_0	2	8	Group 8	01	9a;9b;11b;11c;12;15;		2		2			2		1	20	20
R6801	012	0	1	31	11	R6801_012_0	2	15	Group 15	01	7g;		2		1	15.00	45.00	2		2		
R6801	012	0	1	31	11	R6801_012_0	2	2	Group 2	01	6;11a;		2		2			2		1	50	50
R6801	012	0	1	31	11	R6801_012_0	2	3	Group 3	01	5;		2		1	55.00	55.00	2		2		
R6801	012	0	1	31	11	R6801_012_0	2	4	Group 4	11	7b;	16a;	2		1	20.00	20.00	2		2		
R6801	012	0	1	31	11	R6801_012_0	2	9	Group 9	01	8a1;8a2;8b1;8b2;8b3;		2		1	13.00	16.00	2		1	20	20
R6801	012	0	1	31	11	R6801_012_0	2	6	Group 6	01	7e;7h;9c;		2		1	30.00	40.00	2		2		
R6801	012	0	1	31	11	R6801_012_0	2	5	Group 5	11	7a;18a;	18a;	2		1	15.00	15.00	2		2		
R7444	001	0	1	31	11	R7444_001_0	2	1	Group 1	11	3-1;3-2;3-3;7a;7b;7c;7d;7f;7g;7i;8a1;8b1;8b2;8b3;9a;9b;11b;11c;14d;14e;15;16b;17a;17b;18a;	7f;14b;17a;18a;	2		2			2		1	30	30
R7444	001	0	1	31	11	R7444_001_0	2	10	Group 10	10		18b;	2		1	330.00	380.00	2		2		
R7444	001	0	1	31	11	R7444_001_0	2	2	Group 2	11	9d;	9d;14c;17b;	2		1	0.00	0.00	2		2		
R7444	001	0	1	31	11	R7444_001_0	2	3	Group 3	01	6;11a;		2		2			2		1	50	50
R7444	001	0	1	31	11	R7444_001_0	2	9	Group 9	01	14a;		2		2			2		1	0	30
R7444	001	0	1	31	11	R7444_001_0	2	5	Group 5	01	8a2;		2		1	13.00	13.00	2		2		
R7444	001	0	1	31	11	R7444_001_0	2	6	Group 6	01	7e;7h;9c;		2		1	35.00	45.00	2		2		
R7444	001	0	1	31	11	R7444_001_0	2	7	Group 7	01	5;		2		1	75.00	75.00	2		2		
R7444	001	0	1	31	11	R7444_001_0	2	8	Group 8	01	10a;		2		1	250.00	250.00	2		2		
R7444	001	0	1	31	11	R7444_001_0	2	4	Group 4	01	12;		2		2			2		1	20	20
R9896	008	0	1	31	11	R9896_008_0	4	5	Group 5	10		13b;	1	65.00	1	0.00	0.00	2		2		
R9896	008	0	1	31	11	R9896_008_0	4	4	Group 4	01	17a;		2		2			2		1	0	20
R9896	008	0	1	31	11	R9896_008_0	4	3	Group 3	01	11c;		2		2			2		1	20	30
R9896	008	0	1	31	11	R9896_008_0	4	2	Group 2	11	6;14a;14d;14e;	7f;10b;14c;16a;16b;17a;17b;18a;18b;	2		1	0.00	0.00	2		2		
R9896	008	0	1	31	11	R9896_008_0	4	1	Group 1	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;12;15;16b;17b;18a;	9d;	2		2			2		1	20	20
R9896	009	0	1	31	11	R9896_009_0	2	9	Group 9	01	8a1;8a2;8b1;8b2;8b3;		2		1	13.00	16.00	2		1	20	20
R9896	009	0	1	31	11	R9896_009_0	2	8	Group 8	01	9a;9b;11b;11c;12;15;		2		2			2		1	20	20
R9896	009	0	1	31	11	R9896_009_0	2	7	Group 7	01	17a;		2		1	0.00	45.00	2		2		
R9896	009	0	1	31	11	R9896_009_0	2	6	Group 6	01	7e;7h;9c;		2		1	30.00	40.00	2		2		
R9896	009	0	1	31	11	R9896_009_0	2	5	Group 5	11	7b;	16a;	2		1	20.00	20.00	2		2		
R9896	009	0	1	31	11	R9896_009_0	2	4	Group 4	01	7c;7i;		2		1	40.00	40.00	2		2		
R9896	009	0	1	31	11	R9896_009_0	2	3	Group 3	01	6;11a;		2		2			2		1	50	50
R9896	009	0	1	31	11	R9896_009_0	2	2	Group 2	01	5;		2		1	55.00	55.00	2		2		
R9896	009	0	1	31	11	R9896_009_0	2	15	Group 15	10		17a;	2		1	25.00	25.00	2		2		
R9896	009	0	1	31	11	R9896_009_0	2	14	Group 14	01	7g;		2		1	15.00	45.00	2		2		
R9896	009	0	1	31	11	R9896_009_0	2	13	Group 13	10		18b;	2		1	330.00	380.00	2		2		
R9896	009	0	1	31	11	R9896_009_0	2	12	Group 12	01	10a;		2		1	250.00	250.00	2		2		
R9896	009	0	1	31	11	R9896_009_0	2	11	Group 11	11	7f;9d;14a;14d;14e;17b;	7f;9d;10b;14c;16b;17b;	2		1	0.00	0.00	2		2		
R9896	009	0	1	31	11	R9896_009_0	2	10	Group 10	11	7a;18a;	18a;	2		1	15.00	15.00	2		2		
R9896	009	0	1	31	11	R9896_009_0	2	1	Group 1	01	3-1;3-2;3-3;7d;16b;		2		1	45.00	45.00	2		2		
R9896	012	0	1	31	11	R9896_012_0	3	13	Group 13	10		18b;	2		1	390.00	450.00	2		2		
R9896	012	0	1	31	11	R9896_012_0	3	15	Group 15	01	7g;		2		1	30.00	50.00	2		2		
R9896	012	0	1	31	11	R9896_012_0	3	11	Group 11	11	9d;14a;14d;14e;17b;	9d;14b;14c;16b;17b;	2		1	0.00	0.00	2		2		
R9896	012	0	1	31	11	R9896_012_0	3	10	Group 10	01	5;		2		1	55.00	55.00	2		2		
R9896	012	0	1	31	11	R9896_012_0	3	1	Group 1	11	3-1;3-2;3-3;7d;7f;16b;	7f;	2		1	50.00	50.00	2		2		
R9896	012	0	1	31	11	R9896_012_0	3	14	Group 14	10		17a;	2		1	25.00	25.00	2		2		
R9896	012	0	1	31	11	R9896_012_0	3	12	Group 12	01	10a;		2		1	250.00	250.00	2		2		
R9896	012	0	1	31	11	R9896_012_0	3	2	Group 2	01	7e;7h;9c;		2		1	30.00	40.00	2		2		
R9896	012	0	1	31	11	R9896_012_0	3	3	Group 3	01	6;11a;		2		2			2		1	50	50
R9896	012	0	1	31	11	R9896_012_0	3	4	Group 4	01	7a;		2		1	30.00	30.00	2		2		
R9896	012	0	1	31	11	R9896_012_0	3	5	Group 5	11	7b;18a;	16a;18a;	2		1	20.00	20.00	2		2		
R9896	012	0	1	31	11	R9896_012_0	3	9	Group 9	01	17a;		2		1	0.00	50.00	2		2		
R9896	012	0	1	31	11	R9896_012_0	3	8	Group 8	01	9a;9b;11b;11c;12;15;		2		2			2		1	20	20
R9896	012	0	1	31	11	R9896_012_0	3	7	Group 7	01	7c;7i;		2		1	40.00	40.00	2		2		
R9896	012	0	1	31	11	R9896_012_0	3	6	Group 6	01	8a1;8a2;8b1;8b2;8b3;		2		1	16.00	16.00	2		1	20	20
R9896	021	0	1	31	11	R9896_021_0	4	1	Group 1	11	3-1;3-2;3-3;5;7a;7b;7c;7d;7e;7f;7g;7h;7i;8a1;8a2;8b1;8b2;8b3;9a;9b;9c;9d;10a;11a;11b;12;15;16b;17b;18a;	9d;	2		2			2		1	20	20
R9896	021	0	1	31	11	R9896_021_0	4	2	Group 2	11	6;14a;14d;14e;	10b;14c;16a;16b;17a;17b;18a;	2		1	0.00	0.00	2		2		
R9896	021	0	1	31	11	R9896_021_0	4	3	Group 3	01	17a;		2		2			2		1	0	20
R9896	021	0	1	31	11	R9896_021_0	4	4	Group  4	10		18b;	2		1	330.00	380.00	2		2		
R9896	021	0	1	31	11	R9896_021_0	4	5	Group 5	01	11c;		2		2			2		1	20	30
